ffflSBSBPteBss* 


RD32  SI8H1Q?^054268 

910       Emergency  surgery,  f 


Columbia  Stato?  rsrttp 

College  of  pfjpsictans;  anb  ismrgeons 
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EMERGENCY  SURGERY 

SLUSS 


THE  LEATHER  BOUND   SERIES 


OF 


MEDICAL  MANUALS 


BINNEE.  Operative  Surgery.  By  John  Fairbairn  Binnie,  A.  M.,  C.  M. 
(Aberdeen);  Professor  of  Surgery,  Kansas  State  University;  Member 
American  Surgical  Association. 
Volume  I.  Fourth  Edition.  Operations  on  the  Head,  Neck,  Nerves,  Trunk, 
Genito-Urinary  System,  xi+832  pages  Illustrated  by  713  Engravings, 
some  of  which  are  printed  in  colors.  Flexible  Leather,  Gilt  Edges, 
Round  Corners.  $3-5° 

Volume  II.  Vascular  System,  Bones  and  Joints,  Amputations,  viii+553 
pages.  550  Illustrations.  Flexible  Leather,  Gilt  Edges,  Round 
Corners.  *3-5o 

GREENE.  Medical  Diagnosis.  Third  Edition.  By  Charles  Lyman  Greene, 
M  D  ,  of  St.  Paul,  Professor  of  the  Theory  and  Practice  of  Medicine  in 
the  University  of  Minnesota.  With  7  Colored  Plates  and  248  other  Illus- 
trations. i2mo.  725  pages.  Flexible  Leather,  Gilt  Edges,  Round 
Corners.  *3-So 

HUGHES.  Compend  of  the  Practice  of  Medicine.  Ninth  Edition.  By  Daniel 
E.  Hughes,  M.  D.,  late  Chief  Resident  Physician,  Philadelphia  Hospital. 
Revised  by  Samuel  Horton  Brown,  M.D.,  Assistant  Dermatologist, 
Philadelphia  Hospital.  With  Illustrations.  785  pages.  Flexible 
Leather,  Gilt  Edges,  Round  Corners.  $2.50 

KYLE.  Manual  of  Diseases  of  the  Ear,  Nose  and  Throat.  Second  Edition. 
By  John  Johnson  Kyle,  B.  S.,  M.  D.,  Clinical  Professor  of  Otology, 
Rhinology  and  Laryngology  in  the  Medical  College  of  Indiana;  Otologist, 
Rhinologist  and  Laryngologist  to  the  City  Hospital,  Indianapolis; 
Member  of  the  American  Laryngological,  Rhinological  and  Otological 
Society.  With  169  Illustrations.  Flexible  Leather,  Gilt  Edges,  Round 
Corners.  $3-°° 

SLUSS.  Emergency  Surgery.  Second  Edition.  By  John  W.  Sluss,  A.  M., 
M.  D.,  Professor  of  Anatomy,  Indiana  University  School  of  Medicine; 
formerly  Professor  of  Anatomy  and  Clinical  Surgery,  Medical  College 
of  Indiana;  Surgeon  to  the  Indianapolis  City  Hospital.  With  605  Illus- 
trations. xiv+748  pages.  i2mo.  Flexible  Leather,  Gilt  Edges,  Round 
Corners.  $3-S0 

STEWART.  Manual  of  Surgery.  By  Francis  T.  Stewart,  M.  D.,  Professor  of 
Surgery,  Philadelphia  Polyclinic;  Associate  in  Surgery,  Jefferson  Medical 
College,  Philadelphia,  etc.  504  Illustrations,  ix+778  pages.  Flexible 
Leather,  Gilt  Edges,  Round  Corners.  $3-5° 

THAYER.  Manual  of  Pathology.  131  Illustrations.  General  and  Special. 
By  A.  E.  Thayer,  M.  D.,  Professor  of  Pathology,  University  of  Texas; 
formerly  Assistant  Instructor  in  Pathology,  Cornell  Medical  School. 
With  131  Illustrations.  711  pages.  12  mo.  Flexible  Leather,  Gilt 
Edges,  Round  Corners.  $2.50 

THORNDKE.  Manual  of  Orthopedic  Surgery.  By  Augustus  Thorndike, 
M.  D.,  Assistant  Surgeon  to  the  Children's  Hospital,  Boston;  Member 
American  Orthopedic  Association.  191  Illustrations.  i2mo.  Flexible 
Leather,  Gilt  Edges,  Round  Corners.  $2.50 

***  Other  Volumes  in  Preparation. 


P.     BLAKISTON'S     SON    &    CO. 

Publishers         :  :         PHILADELPHIA 


EMERGENCY  SURGERY 


FOR  THH  GFNFRAL  PRACTITIONER 


BY 

JOHN  W.  SLUSS,  A.M.,  M.D. 

PROPESSOR  OP  ANATOMY,  INDIANA  1'MVERSITY   SCHOOL  op    MEDICINE;   FORMERLY    PROl 

OF     ANATOMY    AND    CLINICAL    SURGERY,    MEDICAL    COLLEGE    OP    INDIANA;    BDROBOM    TO 
THE     INDIANAPOLIS     CITY     HOSPITAL;     SURGEON     TO     THE     CITY     DISPENSARY; 
MKMHER    OP    THE    NATIONAL     ASSOCIATION    OF    MILITARY     SURGE' 


SECOND  EDITION,  REVISED  AND  ENLARGED 

WITH  605  ILLUSTRATIONS 
SO.ME  OF  WHICH    ARE    PRINTED  IN  COLORS 


PHILADELPHIA 

BLAKISTON'S  SON  &  CO. 

1012   WALNUT  STREET 
1910 


First  Edition,  Copyright,  1908,  by  P.  Blakiston's  Son  &  Co. 
Second  Edition,  Copyright,  1910,  by  P.  Blakiston's  Son  &  Co. 

Itlo 


Printed  by 

The  Maple  Press 

York,  Pa. 


DEDICATION 

TO   MY    PRECEPTOR,    DR.    E.    B.    EVANS,    TYPE   AND    EXEMPLAR    OF 

GENERAL    PRACTITIONERS,   IN    MEMORY    OF    DAYS    SPENT 

TOGETHER,   THIS    LITTLE    WORK    IS    INSCRIBED 


PREFACE  TO  SECOND  EDITION 


The  fact  that  the  first  edition  of  this  hook  was  sold  out  within  one 
year  is  particularly  gratifying  to  the  author  because  it  indicates  that 
the  results  of  his  effort  to  make  a  useful  and  practical  book  have  met 
with  the  approval  of  the  profession. 

In  preparing  this  second  edition  of  the  "Emergency  Surgery"  the 
effort  has  been  to  profit  by  the  suggestions  and  criticisms  of  the 
various  reviewers  of  the  first.  It  is  hoped,  in  consequence,  that  its 
usefulness  has  been  increased  and  that  it  will  continue  to  find  favor 
with  its  readers. 

A  new  chapter  on  the  general  technic  of  Laparotomy  has  been 
added;  each  subject  has  been  carefully  reviewed;  and  in  many  in- 
stances new  matter  incorporated.  Thus,  for  example,  Spinal  Anes- 
thesia is  described  in  detail  and  Subphrenic  Abscess  and  Pericardio- 
tomy more  fully  considered. 

Doctor  Helen  Knabe  has  contributed  some  new  illustrations,  and 
the  skiagrams  are  the  work  of  Doctor  Albert  M.  Cole,  of  Indianapolis, 
to  whom  thanks  are  due. 

T.  \V.  s. 


vi  1 


PREFACE  TO  THE  FIRST  EDITION. 

This  is  a  Surgery  for  the  general  practitioner;  written  not  to  instru<  t 
his  leisure  hour,  but  in  the  hope  sometime  to  serve  as  a  guide  out  of 
uncertainty  in  a  time  of  stress.  Its  merits  and  demerits  should  be 
reckoned  from  that  point  of  view  alone.  If,  occasionally,  the  form  of 
expression  seems  dogmatic,  it  merely  comports  with  the  constant  aim 
to  be  practical;  certainly  that  aim  has  denied  any  place  to  theoretic  al 
discussions  and  has  curtailed  reference  to  the  various  views  of  recog- 
nized authority.  An  absence  of  bibliography,  it  is  hoped,  therefore, 
will  not  be  regarded  as  discourtesy  to  the  many  writers,  teachers,  and 
practitioners  whose  ideas  have  been  so  freely  appropriated. 

Among  the  text-books  more  constantly  consulted  are  Senn's  Practical 
Surgery,  The  American  Text-book  of  Surgery,  Walsham's  Surgery, 
Treves'  Operative  Surgery,  Lejars'  Chirurgie  d'Urgence,  Veau's 
Chirurgie  d'Urgence  et  Pratique  Courante,  Von  Bergmann's  Chirurgie, 
and  Binnie's  Operative  Surgery. 

The  Annals  of  Surgery,  the  American  Journal  of  Surgery,  the  Inter 
national  Journal  of  Surgery,  and  the  Journal  of  the  American  Medical 
Association  have  been  prolific  sources  of  information. 

For  advice  and  aid  in  many  ways  in  the  preparation  of  this  book, 
Bpecial  thanks  are  due  Drs.  John  J.  Kyle,  James  H.  Ford,  A.  \V. 
Brayton,  and  Gustav  Bergener.  The  original  illustrations  are  the 
work  of  Dr.  Helen  Knabe. 

To  the  publishers,  through  whose  counsel  and  patient  criticism  the 
book  has  grown  into  its  present  form,  a  grateful  appreciation  is  to  be 
expressed. 

J.  W.  S. 


DC 


CONTENTS 


PART  I. 

CHAPTER  I. 
Tine    General    Practitioner    as     an     Emergency    Surgi 

His  Duties  and  Responsibility:     Equipment i 

CHAPTER  II. 

Emergency  Antisepsis.      Operation  in  a  Private  House       .     . 

CHAPTER  III. 

Anesthesia      11 

CHAPTER  IV. 
Sutures;  Methods  and  Materials 

CHAPTER  V. 
Drainage ag 

CHAPTER  VI. 
Dressings,  Bandages,  Splints       

CHAPTER  VII. 

Shock 49 

CHAPTER  VIII. 
Hemorrhage        5  | 

CHAPTER   IX. 
Wounds:     General  Principles 68 

CHAPTER   X. 

ds  of  Special  Regions       78 

CHAPTER  XI. 
Gunshot  and  Other  Wounds  in  Military  Practice       taa 

CHAPTER   XII. 

Gunshot  Wounds  in  Civil  Practice 155 

xi 


xii  CONTENTS. 

CHAPTER  XIII. 
Fractures        

CHAPTER  XIV. 
Injuries  to  Joints 2S 

CHAPTER  XV. 
Injury  and  Repair  of  Tendons 2£ 

CHAPTER  XVI. 
Injury  and  Repair  of  Nerves       


CHAPTER  XVII. 
Abscess 31 

CHAPTER  XVIII. 
Phlegmon:     Acute  Spreading  Infections 3f 

CHAPTER  XIX. 
Acute  Osteomyelitis 


CHAPTER  XX. 
Septic  Arthritis 


CHAPTER  XXI. 
Foreign  Bodies 


CHAPTER  XXII. 
Burns,  Scalds,  and  Frost-bite 


PART  II. 

CHAPTER  I. 

Tracheotomy,  Laryngotomy,  Esophagotomy 


CHAPTER  II. 
Urgent  Thoracotomy.     Repair  of  Injury  to  the  Lungs.     Re 
pair  of  Injury  to  the  Pericardium.      Repair  of  Injury  to 
the  Heart.     Puncture  of  the  Pericardium.     Pericardiotomy. 

CHAPTER  III. 

Empyema — Purulent  Pleurisy      


CHAPTER  IV. 
Urgent  Craniectomy;  Trephining    .    .    . 


CONTENTS.  XI U 

CHAPTER   V. 
VaStoid  Abscess j^ 

CHAPTER   VI. 
General  Technic  of  Laparotomy 163 

CHAPTER  VII. 
Laparotomy  for  Traumatism 469 

CHAPTER  VIII. 
Appendicitis;  Appendicial  Abscess;  Purulent  Peritonitis   .    .      488 

CHAPTER  IX. 
Acute  Intestinal  Obstruction 508 

CHAPTER   X. 
Artifical  Anus;  Temporary',  Permanent 519 

CHAPTER   XI. 

>RANGULATED    HERNIA 

CHAPTER   XII. 
cal  Cure  of  Inguinal  Hernia       557 

CHAPTER  XIII. 
al  Cure  of  Femoral  Hernia        567 

CHAPTER   XIV. 

UTERECTOMY.        INTESTINAL  ANASTOMOSIS 573 

CHAPTER  XV. 

I  PERFORATE   ANUS       .      .      .      .   ' 584 

CHAPTER  XVI. 
ion  of  the  Pedicle  of  Ovarian  or  Uterine  Tumors;  of 
•:    Spermatic    Cord;    of    the   Pedicle    of   the    Spleen;   of 
Omentum 589 

CHAPTER  XVII. 
pture  and  Hemorrhage  of  Tubal  Pregnancy' 597 

CHAPTER   XVIII. 
kean  Section 604 

CHAPTER   XIX. 

.'TIRE    OF   THE    URETHRA  60S 


XIV  CONTENTS. 

CHAPTER  XX. 
Acute   Retention;  Catheterization;  Supra-pubic  Puncture; 
Cystotomy;  Urinary  Infiltration 619 

CHAPTER  XXI. 
Suture  and  Ligation  of  Arteries 638 

CHAPTER  XXII. 
Practical  Amputations       649 

CHAPTER  XXIII. 

Dilation  of  the  Sphincter  Ani;  Operation  for  Piles;  Opera- 
tion for  Anal  Fistula 703 

CHAPTER  XXIV. 
Phimosis;  Paraphimosis;  Circumcision;  Hydrocele;  Castration    710 

CHAPTER  XXV. 
Ingrowing  Toe-nail 721 

CHAPTER  XXVI. 
Removal  of  Small  Tumors 724 

CHAPTER  XXVII. 
Skin  Grafting 727 

lNDEX ■      733-748 


EMERGENCY  SURGERY. 


UIAI'TKR   I. 


THE    GENERAL    PRACTITIONER    AS   AN    EMERGENCY 

SURGEON:     HIS    DUTIES    AND    RESPONSIBILITY. 

EQUIPMENT. 

Surgery  is  no  longer  reserved  to  the  elect  few.  That  its  beneficence 
shall  he  denied  a  place  in  every  practitioner's  art  is  repugnant  t<>  the 
spirit  of  the  times.  Modern  life  is  complex:  every  profession  and 
every  calling  has  its  specific  duty  to  perform.  Whether  the  medical 
profession  shall  continue  to  play  nohly  its  large  part  in  the  social 
drama  depends  upon  the  general  practitioner.  The  hope  of  the 
profession  rests  in  him.  But  there  is  a  price  to  pay  the  age  for  high 
(pespect.  That  price  to  the  medical  profession  is  nothing  less  than  the 
fulfillment  of  its  therapeutic  promise  and  the  realization  of  its  surgical 
opportunity.  The  opportunity  is  golden;  for,  with  the  wonderful 
Improvements  in  surgical  technic,  the  field  of  emergency  surgery, 
that  is  to  say,  the  indication  for  immediate  intervention,  has  been 
remarkably  hroadened  and  the  time  finds  the  puhlic  singularly  favor- 
able to  that  form  of  relief. 

The  "horror  of  the  knife,"  of  all  that  pertains  to  surgery,  has 
Income  a  tradition,  like  the  practice  which  gave  it  birth.  Indeed,  the 
puhlic  is  trained  to  expect  that,  in  the  face  of  grave  emergencies,  the 
practitioner  will  do  something  effective;  however  serious  the  required 
intervention  may  he,  if  it  hut  offers  hope,  the  doctor  is  expected  to  ai  t. 
Our  predecessors — even  those  able  and  willing — often  found  their 
hands  tied  under  such  circumstances  by  the  ruling  policy  of  "let 
alone  and  let  die."  It  is  a  part  of  their  glory  that  they  conceived, 
planned,  and  attempted  in  the  face  of  tremendous  obstacles,  most  of 
the  interventions  of  urgency  which  are  current  to-day. 


2  THE    GENERAL   PRACTITIONER  AS  AN   EMERGENCY    SURGEON. 

The  surgical  opportunity,  then,  of  the  general  practitioner  is  clear, 
and  his  duty  as  well.  The  professional  spirit,  the  humanities,  his 
conscience,  make  it  incumbent  upon  him  to  know  and  act.  This 
he  must  do  or  drop  to  the  rear  in  the  march  of  progress,  which  does  not 
halt  for  the  timid  or  unwilling. 

But  the  task  imposed  is  heavy,  the  responsibility  large;  for  the  gen- 
eral practitioner  often  finds  himself  isolated,  remote  from  special 
counsel,  perhaps  compelled  to  act  alone.  That  he  does  not  always 
rise  to  the  surgical  emergency  and  do  all  that  he  might  do  even  under 
unfavorable  circumstances,  may  often  be  laid  in  large  part  at  the  door 
of  his  training.  He  knows  often  what  he  ought  to  do,  yet  knows  not 
how  to  do  it.  Happily  the  courses  of  instruction  are  now  generally 
planned  to  do  away  with  this  strange  antithesis  between  theory  and 
practice:  a  theory,  modern,  scientific,  positive;  a  practice,  as  Lejars 
says,  still  often  full  of  error  and  based  on  empiricism  age-old. 

But  this  must  not  be;  for,  now  that  the  indications  for  operation  are 
exactly  defined  and  one's  duty  obvious,  vague  conception  of  an  opera- 
tion as  something  far  away  and  desperate,  must  give  way  to  clear 
notions  of  the  resources  of  surgery,  of  surgical  therapeusis.  Every 
doctor  must  familiarize  himself  with  the  technic  of  interventions 
which  he  must  undertake  at  times,  if  he  is  not  to  be  inexcusably  remiss 
in  an  almost  sacred  duty. 

Surgery  in  one  respect  is  a  handicraft,  and  as  such  requires  its  certain 
tools  of  first  necessity.  If,  as  has  been  said,  emergency  surgery  always 
comes  in  the  nature  of  a  surprise,  then  the  surprise  will  at  least  be  less 
complete  if  one  has  an  equipment  and  has  it  prepared. 

Every  doctor  should  have  an  emergency  bag  supplied  with  mate- 
rials: hand  brushes,  soap,  a  fountain  syringe,  hypodermic  syringe, 
catheters,  flasks  of  alcohol,  ether,  chloroform  and  carbolic  acid,  bi- 
chloride tablets,  a  package  of  sterile  compresses,  sutures,  bandages, 
a  box  of  plaster  of  Paris,  and  certain  instruments. 

Hand  Brushes. — These  are  almost  indispensable  for  emergency  sur- 
gery. They  should  be  kept  well  wrapped  and  should  be  cleansed  with 
soap  and  hot  water  and  sterilized  by  boiling  for  i  minute  before  using. 
New  brushes  should  be  boiled  in  soda  solution  for  five  to  ten  minutes. 


\\  I  [SEW  [(  S.  3 

If  brushes  are  lacking,  one  may  scrub  the  bands  and  the  field  <>f 
operation  with  sterile  gauze.      In  the  hospital  where  the  cleansing  at 

the  time  of  operation  has  been  preceded  by  another  disinfei  tion.  gauze 
may  be  used  to  the  exclusion  of  the  hand  brush. 

Fountain  Syringe  or  Irrigator. — One  may  use  the  full  rubber  out 
fit  or,  what  is  better,  a  porcelain  container  and  a  long  rubber  tube 
with  glass  nozzles.  It  is  absolutely  essential  that  the  whole  be  steril- 
ized by  boiling.  It  is  nonsense  to  sterilize,  as  is  often  done,  the 
cannula'  and  container,  and  neglect  the  tube.  The  glass  nozzles  are 
likely  to  be  broken  if  plunged  directly  into  boiling  water  or  if  cooled 
too  rapidly.  If  the  porcelain  container  is  used,  it  may  be  boiled  ami 
then  singed  with  burning  alcohol.  It  takes  up  but  little  room  in  the 
bag,  and  the  tube  and  nozzles  may  be  wrapped  up  and  packed  in  it 
and  the  whole  wrapped  and  kept  clean  and  dry.  This  outfit  is  almost 
indispensable,  for  in  many  emergencies  the  only  adequate  treatment  is 
by  hypodermoclysis  or  intravenous  infusion. 

The  Antiseptics. — The  alcohol  must  be  kept  in  a  well  stopped  tla^k 
and  the  carbolic  acid  or  lysol,  also.  The  bichloride  may  be  in  the  form 
of  tablets,  so  that  the  strength  of  a  solution  may  be  readily  calculated. 
The  most  commonly  employed  is  the  formula  containing  mercury  bi- 
chloride 7.3  gr.,  citric  acid  3.8  gr.  This  tablet  in  one  quart  of  water 
makes  a  1  to  2000  solution,  which  is  as  strong  as  need  be  used.  One 
to  three  pints  makes  a  1  to  3000  solution,  and  so  on.  Instead  of  the 
tablets,  one  may  keep  a  concentrated  solution  of  bichloride  in  alcohol. 

Bichloride  of  Mercury,  5j- 

Alcohol,  5]. 

One  teaspoonful  to  a  quart  of  water  makes  a  1  to  2000  soluti<  'ii ; 

One  teaspoonful  to  3  pints,  1  to  3000,  etc. 

Many  English  operators  prefer  a  solution,  1-4000  biniodide  of  mer- 
cury. A  one-half  ounce  bottle  of  Tr.  iodine  should  be  carried  ami 
will  be  found  excellent  for  emergency  sterilizations  of  the  skin. 

Anesthetics. — One  should  keep  on  hand  at  least  one  pint  of  ether 
and  four  to  six  ounces  of  chloroform.  Cocaine  for  local  anesthesia 
is  best  kept  in  tablet  form  and  the  solutions  made  extemporaneously. 

For  example,  2  1/2-grain  tablets  of  cocaine  to  t  teaspoonful  of  sterile 
water   makes  a   2   per  cent,   solution;  4    1/2-grain   tablets   to   a   tea- 


4  THE   GENERAL   PRACTITIONER  AS  AN   EMERGENCY    SURGEON. 

spoonful  of  water  makes  a  4  per  cent,  solution;  10  1/2-grain  tablets, 
a  10  per  cent,  solution.  This  is  not  exact,  of  course,  but  furnishes  a 
good  working  rule  for  the  emergency.  Ethyl  chloride  for  local  freez- 
ing is  put  up  in  small  containers  convenient  for  the  emergency  bag. 

Sterile  Gauze. — Too  frequently  the  practitioner  commits  the  error 
of  depending  upon  absorbent  cotton  for  his  sponges  and  compresses. 
Absorbent  cotton,  as  found  on  the  market,  is  scarcely  ever  aseptic. 
Even  if  it  is,  it  is  almost  certain  to  be  contaminated  in  getting  it  out 
of  the  package.  A  supply  of  sterile  gauze  is  one  of  the  best  means  of 
promoting  an  aseptic  operation.  It  should  be  kept  in  a  hermetically 
sealed  package  of  metal  or  glass.  ' 

In  lieu  of  the  gauze  compresses  ready  sterilized,  one  may  carry  a 
supply  of  ordinary  gauze  which  can  be  cut  into  appropriate  sizes,  and 
sterilized  at  the  time  of  operation.  It  is  a  good  idea  to  cut  two  sizes; 
a  small  for  compresses  and  wipers,  a  larger  to  cover  the  field  of  opera- 
tion. All  these  pieces  should  be  folded  once  and  the  borders  hemmed. 
A  ball  of  cotton  may  be  hemmed  in  between  the  layers,  which  makes  a 
still  better  sponge. 

Sutures  and  Ligatures. — If  these  materials  are  not  already  sterilized 
and  in  a  special  package  or  container,  such  as  a  sealed  tube  of  alcohol, 
catgut  must  be  ruled  out,  for  its  preparation  takes  too  much  time.  One 
should  take  care  to  have  several  sizes  of  silk,  especially  the  o  and  00; 
for  these  are  the  sizes  required  in  intestinal  work.  Silk  and  silk- 
worm-gut may  be  sterilized  as  needed. 

Catheters  and  bougies  should  be  kept  in  a  metallic  box.  Rubber 
and  metal  catheters  are  always  readily  sterilized  by  boiling.  Rubber 
catheters  deteriorate  rapidly  unless  properly  cared  for.  They  may 
break  unexpectedly,  the  result  of  an  unnoticed  change  in  quality,  and  a 
piece  be  left  in  the  bladder. 

Drainage  Tubes. — These  should  be  preserved  in  a  box  or  bottle 
which  may  be  boiled  thoroughly  before  opening. 

Plaster  should  be  kept  in  a  tin  box  with  tight  cover  and  may  be 
loose  or  already  rolled.  A  supply  of  roller  bandages  is,  of  course, 
always  kept  on  hand,  from  which  the  plaster  bandages  may  be  made. 

Instruments. — Any  list  which  might  be  enumerated  must,  of  course,  be 
subject   to   the  widest  variation.     But  the  feeling  of  greatest  confi- 


i  \ui     OS    [NSTRUMENTS. 

dence  goes   with   the  consciousness  <>i"  having  th<  ry  things 

with  which  to  act.  On  the  whole,  the  doctor  should  pride  bimsell 
upon  the  completeness  <>f  his  outfit,  rather  than  upon  his  ability  to 
improvise.  One  should  have  as  the  minimum:  scalpels,  two 
of  amputating  knives,  scissors,  grooved  director,  dissecting  forceps, 
artery  forceps — the  more  the  better — two  retractors,  a  law,  a  bone 
chisel,  needle  holder  and  needles,  tracheotomy  tubes,  and  an  Esman  h 
lube.  The  instruments  most  frequently  used  may  In-  put  together  in 
a  small  metal  case,  while  the  others  may  lie  kept  in  larger  cas< 
wrapped,  or  rolled  up  in  a  bundle. 

Cleaning  instruments  and  preserving  them  from  rusl  is  a  matter  <>\ 
no  small  importance.  After  each  operation  they  should  be  taken 
apart,  scrubbed  with  soap  and  warm  water,  wiped  with  gauze  satu- 
rated with  alcohol,  and  dried  thoroughly.  If  the  cleansing  has  been 
delayed,  it  may  be  necessary  to  immerse  them  for  a  short  time  in  a 
solution  of  potash,  and  finally  cleanse  in  the  manner  described.  If 
any  stains  still  persist  they  should  be  polished  with  chamois  skin. 

Formaldehyde,  certain  acids,  and  iodine  in  too  (lose  proximity, 
tarnish  and  spoil  instruments  in  spite  of  care. 

A  dish  or  two  of  calcium  chloride  in  the  instrument  case  will  absorb 
moisture  and  tend  to  prevent  rusting.  Too  often  the  practitioner 
neglects  his  instruments  because,  perhaps,  not  often  used;  and,  in  the 
emergency,  he  finds  himself  with  knives  rusty  and  without  an  edge, 
scissors  that  will  not  cut,  and  forceps  that  have  no  grip.  He  will 
certainly  gain  time  by  spending  a  little  time  in  carrying  out  these  small 
details. 


CHAPTER  II. 

EMERGENCY     ANTISEPSIS.      OPERATION    IN    A    PRIVATE 

HOUSE. 

The  preparation  for  an  urgent  intervention  outside  of  an  operating 
room  resolves  itself  into  a  question  of  asepsis  or  antisepsis,  and  around 
this  point  gathers  a  multitude  of  details.  But  it  is  necessary  only  to 
proceed  systematically  and  intelligently  to  achieve  excellent  results. 

The  time  was  when  the  idea  prevailed  that  an  aseptic  operation 
was  scarcely  possible  outside  a  hospital.  This  was  a  harmful  notion 
which  restrained  many  a  practitioner  from  an  effort  that  might  have 
saved  his  patient's  life.  Every  day  it  is  demonstrated  that  aseptic 
work  is  not  peculiar  to  formal  operating  rooms. 

Bonney,  of  Philadelphia,  writes  that  he  has  done  many  major  opera- 
tions in  the  homes  of  the  poor  in  the  midst  of  the  most  unsurgical 
surroundings;  nevertheless,  the  results  have  been  excellent.  Most 
of  these  operations  were  for  urgent  abdominal,  pelvic,  or  genito-urinary 
disease,  and  though  such  work  is  often  time-consuming  and  laborious, 
yet  it  shows  what  can  be  done  in  the  case  of  necessity.  Bonney  at- 
tributes his  success  with  inflammatory  conditions  to  complete  removal 
of  diseased  tissue  and  free  drainage  in  pus  cases. 

Van  der  Walker  (Month  Cyclopedia  of  Pract.  Med.,  Aug.,  1906) 
says  that  for  thirty  years  he  has  operated  in  farm  houses  throughout 
central  New  York  with  as  good  results  as  those  obtained  in  the  hospital 
with  which  he  was  connected  for  many  years.  He  goes  further 
and  concludes  that,  for  many  reasons,  it  is  desirable  that  there  should 
be  a  return  to  more  home  operating,  and  that  the  hospital  ought  to  go 
back  to  the  original  purpose,  the  care  of  the  homeless  and  sick  poor, 
and  not  invade  the  home  with  the  arrogant  assurance  that  only  within 
its  walls  can  the  surgical  case  be  cared  for. 

But  this  is  aside  from  the  main  point:  the  practitioner  may  feel 

6 


BOILING     I  in     [NS1  R1   Ml 

assured  that  with  decision,  knowledge,  and  tysU  m,  <   <n  under  appai 

unfavorable  circumstances,  he  can  nearly 

asepsis. 

As  Lejars  says,  everywhere  one  finds  water,  fire,  and  linen;  add  salt 
and  usually  carbonate  of  soda:  with  these  one  may  accomplish  a 
sufficient  sterilization  of  the  instruments,  the  hands,  the  field  of  opera 
tion  and  the  dressing.  But  it  requires  a  will  to  do  all  the  work,  to 
proceed  with  method  and,  above  all,  quickly,  through  the  minutia 
of  preparation.  One  should  have  a  plan  in  mind  and  Lejars  offers  a 
model  which,  of  course,  tan  be  modified  to  suit  the  circumstances  and 
the  operation.  Suppose  a  major  emergency,  with  every  detail  of 
the  preparation  to  be  supervised: 

First  Step. — Have  a  fire  started.  Have  the  available  receptacles 
assembled.  Review  the  stock  of  linens  if  you  do  not  hi 
or  muslin.  Freshly  laundered  handkerchiefs  and  napkins  (without 
fringe)  furnish  material  for  excellent  compresses  and  coverings 
for  the  field  of  operation.  Secure  one  or  two  large  kettle-  a  copper 
wash-boiler — for  boiling  the  water  for  the  operation.  Secure  three 
smaller  receptacles  such  as  enameled  stewing  pans:  one,  for  boiling 
the  instrument  and  sutures;  another,  for  the  brushes,  irrigator,  nozzles 
and  tube,  etc.:  the  third,  for  the  compresses  and  tampons,  [f  pos 
sible,  boil  also  the  dishes  or  basins  selected  to  hold  the  instruments  and 
the  solutions  needed  during  the  operation.  It  is  best  to  have  a  dish  or 
howl  for  the  instruments,  one  for  the  tampons  and  compresses,  one  for 
the  sutures,  and  two  hand  basins  for  sterile  water  and  bichloride  solu- 
tion. The  boiling  must  be  prolonged  at  least  a  halt"  hour  to  be  sure  ol 
sterilization.  It  is  a  good  plan  to  add  a  teaspoonful  of  sail  to  the 
quart  of  water  containing  the  compresses  which  are  to  be  tied  up 
in  a  towel  to  facilitate  their  removal;  and  to  add  a  teaspoonful  of 
washing  soda  to  the  water  in  which  the  instruments  are  to  boil,  since 
it  more  readily  removes  grease  or  blood,  makes  the  temperature  slightly 
higher,  and  prevents  rusting.  The  knives  should  be  wrapped  in  soft 
gauze  to  prevent  dulling.  The  instrument-  ought  not  to  be  put  in 
until  the  water  is  boiling,  as  otherwise  they  are  likely  to  he  tarnished. 
If  it  is  necessary  to  boil  the  instruments  and  suture  material  together, 
the  soda  should  not  be  added,  since  it  rapidly  ruins  both  silk  and  silk- 


8  EMERGENCY  ANTISEPSIS. 

worm-gut.  ,  Even  better  than  boiling  water  for  sterilizing  instruments 
is  hot  oil — olive  oil,  for  example — since  its  boiling-point  is  a  higher  than 
that  of  water.  The  vessel  containing  the  oil  can  be  set  in  another  of  cold 
water  and  instruments  may  soon  be  taken  from  the  oil  ready  for  use. 
This  oil  may  be  used  again  many  times  Five  minutes  of  actual  boiling 
is  sufficient  to  sterilize  instruments.  When  once  the  sterilization 
is  under  way  proceed  to  the  operating  room. 

Second  Step.  Prepare  the  Operating  Room  and  Table. — If  there  is' 
any  choice,  select  the  best  lighted  and  largest  room.  If  it  is  at  night, 
arrange  for  the  illumination.  Do  not  displace  the  furniture  except  to 
make  room  for  the  operating  table,  two  small  tables,  and  room  to  "turn 
about."  An  extensive  "clearing  for  action"  does  more  harm  than 
good,  for  by  jerking  down  the  curtains,  rolling  the  furniture  around 
and  sweeping,  one  stirs  up  the  dust,  accumulating  perhaps  for 
months. 

It  is  preferable  simply  to  sprinkle  the  floor  or  wipe  with  a  wet  cloth. 
To  be  sure,  if  one  has  several  hours  in  which  to  prepare,  then  the  room 
may  be  emptied,  the  floor  covered  with  moist  sheets  and  the  walls 
sprayed,  as  Quenu  suggests,  with  peroxide,  the  tables  placed  and  the 
room  closed  until  the  time  of  operating. 

It  is  never  a  good  idea  to  use  the  patient's  bed  for  an  operating 
table,  although  the  first  preparation,  as  the  shaving,  may  be  begun  there. 
The  dining  table  can  usually  be  pressed  into  service,  covered  with  a 
blanket  and  that  with  an  oilcloth.  A  table  may  be  improvised  from 
two  wooden  trestles  with  planks  laid  across  and  covered  like  the  table. 
Of  the  two  small  tables  required,  the  one  on  the  assistant's  side  will 
hold  the  compresses,  sutures,  etc.;  the  other  on  the  operator's  side 
will  hold  the  instruments. 

Now  give  the  patient  the  preliminary  preparation.  Shave  the 
parts  always  when  possible,  first  lathering  with  soap  and  hot  water. 
The  razor  is  almost  indispensable  as  an  agent  of  disinfection,  for  it 
removes  the  hair  and  the  superficial  layer  of  the  epidermis.  It  is  a 
common  fault  to  be  too  sparing  with  its  use.  In  operations  on  the 
skull,  the  whole  scalp  should  be  shaved.  The  shaving  may  be  done 
after  the  patient  is  anesthetized;  but,  as  a  rule,  everything  possible 
should  be  done  to  curtail  the  anesthesia.     If  the  operation  is  likely  to 


PREPA&A  1 1<>\    "i     i  in:    n  wns. 

be  prolonged,  wrap  the  lower  Limbs  In  blankets,  and  speak  for  1 1  ■  > t 
irons  or  water  bottles. 

Third  Step. — Everything  having  boiled  sufficiently,  carry  thi 
into  the  operating  room  and  empty  the  contents  of  ea<  li  into  it-  spe<  i.il 
receptacle,  which  of  course  must  firsl  be  sterilized. 

If  these  bowls  have  not  been  boiled,  as  previously  < I i r«i  ted,  now  is  the 
tinu-  to  sterilize  them  by  singeing  with  burning  alcohol.  Into  eai  li  pour 
two  or  three  s|)oonfuls  of  altolml  andsetiton  fire,  in  the  meantime  till 
lug  the  dish  in  various  directions  so  that  the  flame  is  brought  in  contact 
with  the  whole  inner  sulfate.  When  this  is  done,  lift  the  compn 
and  instruments  out  of  their  boilers,  place  them  in  these  sterile  dishes 
and  cover  them  with  an  antiseptic  solution.  This  protects  them  from 
(possible  contamination  until  the  operation  begins.  Do  not  open  the 
bag  of  compresses  till  needed.  Remember  to  use  only  a  sterile  dipper, 
if  necessary  to  dip  out  the  sterile  water  in  preparing  the  various 
solutions. 

Fourth  Step. — Direct  the  assistant  to  begin  the  anesthesia,  and  now 
prepare  your  hands.  As  Lejars  remarks,  this  is  a  "science  and  art," 
the  first  duty  of  the  surgeon.  They  are  not  to  be  prepared  by  a  desul- 
tory rinsing  in  soapy  water,  or  parboiling  with  a  hot  antiseptic  solu 
tion,  but  by  a  patient  and  systematic  scrubbing.  Get  your  sleeves 
rolled  up  and  pinned.  Have  before  you  two  wash  basins,  one  with 
hot  and  the  other  with  cold  sterile  water.  Pare  the  nails.  Begin 
with  soap  and  hot  water.  Lather  the  arms  up  to  the  elbow,  and  rub 
the  soap  in  until  the  skin  seems  saturated  and  soft.  Then  begin  with 
the  brush;  scrub  the  palms,  the  dorsum  of  the  hand,  between  the  ful- 
lers, all  about  the  nails.  One  need  not  rub  the  skin  off,  to  be  sure,  but 
the  disinfection  must  be  complete.  The  water  should  be  changed 
several  times,  if  possible;  next  rinse  in  cold  sterile  water  and  then  rub 
vigorously  with  alcohol  to  remove  all  the  oils  in  the  skin;  finally  soak 
in  bichloride  solution.  The  cleansing  will  probably  occupy  ten  nun 
utes.  The  antiseptics  used  vary  with  the  operator,  but,  after  all,  it  is 
the  soap  and  hot  water  which  is  most  important.  Rubber  gloves  are 
always  used  by  some  operators  and  doubtless  to  some  advantage. 
They  are  probably  an  extra  guarantee  against  infection,  but  are  b)  no 
means  indispensable.     As  good  plan  as  any,  perhaps,  is  to  use  them 


IO  EMERGENCY   ANTISEPSIS. 

always  where  infective  processes  are  likely  to  be  met  with  ;  and  thus  the 
operator  is  protected ;  and,  besides,  his  hands  are  kept  free  from  septic 
agents  which  might  be  difficult  to  remove. 

Fifth  Step. — In  the  meantime  the  anesthesia  has  progressed.  When 
it  is  well  under  way,  prepare  the  field  of  operation,  which  we  assume 
has  been  previously  shaved,  by  scrubbing  with  soap  and  water,  followed 
by  alcohol  or  ether  and  bichloride  solution.  Harrington's  solution  is 
much  employed  and  consists  of 

Mercuric  chloride,  .8  g. 

Acid  hydrochloric,  60      c.c. 

Water,  300      c.c. 

Alcohol,  640      c.c. 

Konig  refrains  from  scrubbing;  and,  instead,  paints  the  field  of  opera- 
tion with  Tr.  of  iodine,  first  shaving  the  part  after  an  ordinary  bath 
(Berlin.  Klin.  Wochenschrift,  April  26,  1909).  However,  certain 
regions,  as  the  scrotum  and  perineum,  are  too  sensitive  for  this  method 
of  preparation.  But,  whatever  method  may  be  employed,  the  disin- 
fection of  the  skin  must  be,  in  every  respect,  as  thorough  and  vigorous  as 
that  of  the  hands,  and  must  extend  well  beyond  the  proposed  line  of  incision 
in  all  directions,  for  one  can  never  tell  where  the  incision  may  finally 
end.  A  large  area  is  almost  as  rapidly  prepared  as  a  small  one. 
For  example,  in  laparotomies  the  whole  abdomen  should  be  included, 
as  well  as  the  lower  half  of  the  thorax.  In  hernia  operations,  the 
abdomen  as  far  as  the  umbilicus,  the  groin  and  the  genitals.  In 
amputations  of  the  leg,  the  thigh  should  be  included  in  the  cleansing; 
and  in  amputations  of  the  thigh,  the  whole  region  of  the  pelvis. 

Again  wash  your  hands.  An  untrained  assistant  changing  the 
bowls  may  spoil  the  sterilization  by  getting  his  fingers  or  thumbs 
inside.  Direct  him  how  to  lift  and  carry  a  bowl  with  his  palms  against 
the  outside. 

Having  completed  the  final  cleansing  of  the  hands,  cover  the  field 
of  operation  on  the  four  sides  with  four  sterile  towels  or  large  com- 
presses and  fasten  them  with  sterile  safety  pins  or  artery  forceps. 

Time  gained  by  relaxing  in  the  least  any  of  these  precautions  of 
asepsis  and  antisepsis,  is  irretrievably  lost;  it  is  the  operation,  now 
begun,  which  must  progress  rapidly. 


CHAPTER  III. 
ANESTHESIA. 

Anesthesia  is  necessary  in  most  emergency  operations,  not  only  to 
obviate  pain,  but  because  it  is  often  essential  to  a  good  operation. 
Unfortunately,  on  the  other  hand,  it  adds  to  the  doctor's  task  and  pre- 
sents some  special  difficulties. 

In  certain  grave  conditions,  as  intestinal  occlusion,  strangulated 
hernia,  or  abdominal  traumatism,  it  may  be  the  actual  cause  of  death, 
however  carefully  administered. 

Not  only  in  emergency  work,  but  in  any  case,  general  anesthesia 
should  be  cautiously  induced  and  narrowly  watched;  and  for  this 
reason  it  is  especially  embarrassing  to  the  doctor  compelled  to  entrust 
it  to  the  untrained  in  cases  of  urgency. 

Chloroform  has  the  advantage  that  it  requires  no  special  apparatus 
for  its  administration;  and  the  smaller  bulk  is  an  item  of  importance, 
especially  in  military  practice;  moreover,  it  is  much  more  pleasant  to 
the  patient.  Unfortunately,  it  is  many  times  more  dangerous  than 
ether,  even  in  the  hands  of  the  skilled. 

In  lieu  of  a  special  inhaler,  such  as  Esmarch's,  fold  a  handkerchief, 
napkin,  or  compress  several  times  to  form  a  square.  Begin  by  pouring 
on  several  drops  and  gently  approaching  it  to  the  mouth  and  nose  of 
the  patient.  The  inhaler  should  be  managed  with  the  left  hand, 
leaving  the  right  hand  free  to  raise  the  eye-lid,  or  feel  the  pulse,  or 
handle  the  container.  Do  not  hold  it  too  close  to  begin  with,  but  give 
the  patient  plenty  of  air;  in  other  words,  give  the  chloroform  well  diluted. 
Give  the  patient  time  to  get  accustomed  to  the  odor.  Advise  him  to 
breathe  through  the  mouth  and  distract  his  attention  as  much  as  possi- 
ble; get  his  confidence,  flatter  him,  and,  in  the  meantime,  study  him  and 
test  him.     The  few  minutes  spent  in  this  way  will  soon  be  regained. 

Pour  on  five  or  six  drops  of  chloroform  at  a  time;  and,  as  the  respira- 
tion becomes  deeper,  hold  the  inhaler  closer,  giving  the  chloroform  less 


1 2  ANESTHESIA. 

diluted  with  air.  Replenish  the  supply  every  half  minute,  sprinkling 
it  on  the  under  side  of  the  compress  and  quickly  inverting  it  over  the 
face. 

As  the  stage  of  excitement  comes  on,  push  it  more.  When  the 
anesthesia  is  complete,  reduce  the  dosage  but  increase  the  frequency 
of  renewal. 

The  drop  method  is  ideal  after  the  anesthesia  has  been  attained. 
Small  doses  frequently  applied  mean  the  smallest  total  amount,  which 
must  be  the  anesthetist's  constant  aim  (Fig.  i). 

The  good  anesthetist  is  not  the  one  who  can  use  the  largest  amount 
of  chloroform  without  death,  but  the  one  who  can  hold  the  patient 
merely  unconscious  and  relaxed  with  the  smallest  amount  possible. 


Fig.  i. — Chloroform  container. 


If  the  patient  coughs  or  shows  signs  of  nausea,  increase  the  dosage 
at  once.  Do  not  begin  the  preparation  of  the  field  or  any  part  of  the 
operation  until  the  anesthesia  is  complete. 

Keep  the  pulse,  the  pupil,  the  face,  and  the  thorax  under  constant 
surveillance,  for  in  this  way  alone  may  one  determine  the  prognosis, 
good  or  bad,  of  the  anesthesia. 

The  anesthesia  is  usually  described  as  occurring  in  three  stages: 
the  first,  stage  of  excitement;  the  second,  loss  of  consciousness;  the 
third,  loss  of  reflexes  or  stage  of  surgical  anesthesia.  There  is  a  fourth, 
stage  of  paralysis  of  the  automatic  centers,  but  this  is  a  stage  which  the 
good  anesthetist  will  never  reach. 

The  excitement  of  the  initial  stage,  in  which  the  patient  struggles 
or  talks  at  random,  is  followed  by  loss  of  consciousness,  but  the  reflexes 


ETIIF.K    A\l  SI  III  SIA.  I  | 

arc  active,  the  pulse  is  full  and  bounding,  the  pupils  respond  to  light, 

the  eye  lid  resents  the  corneal  touch,  the  skin  is  sensitive,  the  face  is 
flushed,  and  the  breathing  deep  and  regular. 

Beware  at  this  time  of  sudden  blanching  of  the  fate,  of  dilated  pupils, 
of  weakened  pulse,  or  disturbed  breathing.      If  these  symptoms  arise, 

Withdraw  the  anesthetic  and  prepare  for  artificial  respiration.  The 
patient   is   not   ready   for   the  operation   and   yet  he  may  die  in   this 

stage. 

Often  pallor  and  dilated  pupils  precede  vomiting,  but  when  the  pulse 

and  respiration  are  good,  the  nausea  is  to  be  quieted  by  more 
chloroform. 

When  the  reflexes  are  finally  abolished,  the  pulse  should  be  full. 
though  perhaps  a  little  slowed,  the  respiration  quiet  and  regular,  the 
pupils  slightly  contracted,  and  the  face  moderately  pale.  Any  marked 
deviation  from  this  standard  during  the  operation  is  a  matter  for 
concern. 

Weak  heart  action,  uncertain  respiration,  dilated  pupils,  deep 
pallor  or  cyanosis,  mean  approaching  paralysis  of  the  automatic  cen- 
ters governing  the  circulation  and  respiration,  and  the  anesthetic  must 
be  withdrawn  until  the  symptoms  improve  under  measures  employed 
to  stimulate. 

In  the  case  of  the  average  adult,  one  and  one-half  to  two  ounces 
should  be  sufficient  for  the  first  hour  and  much  less  subsequently. 
Children  and  the  debilitated  require  less. 

Ether  has  the  disadvantages  in  emergency  work  that  it  is  dangerous 
to  use  near  a  light  or  lire,  and  that  its  administration  is  a  little  more  com- 
plicated; but,  beyond  that,  its  anesthesia  is  never  attended  by  sudden 
death  in  the  early  stages,  as  is  that  of  chloroform.  It  is  followed  by  less 
shock  after  abdominal  operations  or  other  prolonged  intervention. 
Bronchial  affections  are  its  chief  counterindications.  An  inhaler  may 
be  fashioned  out  of  a  newspaper  rolled  into  a  cone,  cotton  or  gauze 
being  fastened  in  its  apex,  on  which  the  ether  is  poured.  Begin  with  a 
drachm;  let  the  patient  get  accustomed  gradually  to  the  ether,  diluting 
it  well  with  air  by  holding  the  inhaler  an  inch  or  so  from  the  face 
and  gradually  approaching.  In  that  way,  the  feeling  of  suffocation  is 
avoided.     As  the  patient  approaches  unconsciousness,  hold  the  mask 


14  ANESTHESIA. 

closely  so  as  to  shut  out  the  air,  and  the  stage  of  anesthesia  will  be  I 
quickly  reached  without  excitement. 

If  one  proceeds  timidly  at  this  stage,  the  anesthesia  will  be  hard  to 
obtain  and  much  more  ether  will  be  required.  Once  the  reflexes  are  j 
abolished,  use  small  quantities,  frequently  applied.  The  "drop 
method"  may  be  employed  with  ether  as  well  as  with  chloroform, 
and  reduces  the  danger  to  the  minimum.  The  accident  most  to  be 
feared  is  respiratory  paralysis. 

The  signs  indicating  the  favorable  progress  of  ether  anesthesia  during  ! 
the  operation  are:  pulse  full  and  regular;  respiration  deep  and  slightly 
snoring;  face  flushed;  and  pupils  slightly  dilated.     Cyanosis  is  the  J 
signal  for  more  oxygen.     Any  disturbance  of  the  respiration  demands  j 
immediate  attention.     For  excessive  mucous  formation,  Ford  recom- 
mends spraying  on  the  mask  at  intervals  of  five  or  six  minutes,  when 
necessary,  an  adrenalin  solution.     Three  parts  of  water  to  one  part 
adrenalin  solution  (i-iooo)  are  used  in  an  ordinary  atomizer.     Ford 
claims   that  it   also   acts   as   a   circulatory   stimulant.     Occasionally 
patients  will  be  found  who  do  not  take  ether  well,  but  who  will  take 
chloroform  without  the  least  untoward  effect. 

TREATMENT  OF  THE  ACCIDENTS  OF 
ANESTHESIA. 

Certain  measures  are  recommended  as  forestalling  the  dangers 
of  anesthesia ;  though  they  are,  as  a  rule,  more  appropriate  in  the  general 
surgery  of  hospitals. 

A  preliminary  gastric  lavage  will  save  embarrassment  in  certain 
cases.  In  fact,  this  should  be  an  invariable  rule,  when  compelled  to 
operate  on  patients  who  have  eaten  only  a  short  time  previously.  A. 
preliminary  subcutaneous  injection  of  normal  salt  solution  will  sustain 
the  patient  in  the  cases  of  anemia  and  grave  septic  infection. 

Many  surgeons  precede  a  chloroform  anesthesia  by  hypodermic 
injection  of  morphia  or  strychnia.  Boldt  (Med.  Record,  May  29, 
1909)  condemns  as  dangerous  the  practice  of  preceding  a  general 
anesthesia  by  the  morphia-scopolamine  narcosis.  He  recommends, 
however,   for  patients  who   are   apprehensive  and  nervous  a  single  I 


ARTIFICIAL    RESPIRATION.  I  5 

dose  of  morphia  and  atropia  thirty  minutes  before  the  anesthesia  is 
given.  This  is  desirable  too  in  operations  on  regions  in  which  the 
reflexes  are  more  active,  for  there  is  scarcely  a  doubt  that  some  of  the 
circulatory  disturbances  under  chloroform  are  reflected  from  the  field 
of  operation.  This  is  true  of  the  testicle,  the  spermatic  cord,  the  anus. 
and  the  peritoneum.  None  of  these  methods  lessens  the  anesthetist's 
responsibility  and  duty  to  watch  every  point. 

If  the  circulation  grows  weak,  the  pulse  small,  rapid, compressible, 
due  to  the  effect  of  the  anesthetic  agent  and  not  to  shock  or  hemorrhage, 
withdraw  the  agent  and  lower  the  head,  draw  out  the  tongue  and  begin 
artificial  respiration,  and  the  danger  is  usually  soon  passed. 

Hypodermic  injection  of  stimulants,  such  as  strychnia  or  camphor- 
ated oil,  often  do  good  under  these  circumstances;  but  when  the 
circulation  is  paralyzed  and  syncope  has  supervened,  their  use  is 
illusory.  Do  not  waste  time  preparing  them,  though  an  assistant  may 
do  so;  but  proceed  to  make  rhythmic  traction  on  the  tongue,  and 
artificial  respiration,  both  being  carried  out  methodically.  If  an 
assistant  is  at  hand,  carry  out  the  two  measures  simultaneously; 
otherwise,  try  the  tongue  traction  first,  or  at  least  get  it  pulled  out  well. 
Traction  of  the  tongue  to  do  good,  must  be  rhythmic.  The  tongue 
must  be  caught  up  carefully  with  forceps  and  no  force  must  be  used. 
Often  the  tongue  is  seriously  injured  by  the  feverish  pulls  of  the  agitated 
operator,  who  has  quite  forgotten  that  the  maneuver  is  effectual  only 
when  rhythmic.     Likewise,  the  artificial  respiration  must  be  rhythmic. 

Grasp  the  patient's  elbows  and  draw  them  gently  and  steadily  up- 
ward until  they  meet  above  the  head.  The  pectoral  muscles  are  put 
upon  the  stretch  and  the  chest  expanded  and  inspiration  produced. 
At  the  same  time  the  tongue  is  drawn  outward  (Fig.  2). 

The  arms  are  next  brought  with  a  steady  movement  to  the  chest 
wall  and  the  diaphragm  compressed.  (Stage  of  expiration.)  At 
the  same  time,  the  tongue  is  permitted  to  retract  (Fig.  3). 

These  movements  are  to  be  repeated  at  the  rate  of  about  twenty 
per  minute  and  should  be  persisted  in  without  intermission  for  at  least 
:i  half  hour  before  giving  up  hope  of  resuscitation. 

Direct  compression  of  the  heart  is  a  procedure  of  real  value  and  it 
may  often  be  readily  managed  through  the  abdominal  walls.     In  the 


i6 


ANESTHESIA. 


case  of  abdominal  operations,  the  hand  may  be  passed  up  the  to  dia- 
phragm and  the  heart  seized  and  kneaded  in  that  manner. 

The  vomiting  after  anesthesia  is  often  troublesome  and  is  usually  in| 
direct  ratio  with  the  amount  of  the  agent  used.     Every  effort  should; 


Fig.  2.— Stage  of  inspiration.     Tongue  should  be  drawn  out  with  this  movement.      {Stewart.. 


be  made  to  hasten  its  elimination  from  the  blood  by  keeping  the  skir 
warm  and  active,  and  helping  the  kidneys  with  saline  enemata.  These 
enemata  also  diminish  thirst.     Warm  soda  water  drunk  freely  help: 


FlG  3 — Stage  of  expiration.     Tongue  permitted  to  drop  back  in  mouth. 

to  wash  out  the  stomach  and  thus  hastens  relief  of  actn 
Five  to  fifteen  drops  of  aromatic  spirits  of  ammonia  hypo 
or,  well  diluted,  by  mouth,  often  does  good. 

Other  forms  of  general  anesthesia  will  not  often  be  of 


I",    \|.    .WKSTIII  SIA. 


'7 


Emergency  practice  for  obvious  reasons,  however  valuable  they  may 
otherwise  be.  It  is  hardly  necessary,  therefore,  to  consider  nitrous 
oxide  or  ethyl  chloride  and  their  conveners;  or  general  anesthesia  by 
■ray  >>i"  the  rectum,  which  promises  to  l»e  of  value  in  operations  on  the 

la.  e,  mouth,  Deck;  and  thorax. 

LOCAL  ANESTHESIA. 

The  doctor,  isolated  and  without  assistants,  will  many  times  find 
aid  and  comfort  in  local  anesthesia  by  hypodermic  injection;  hut  to  be 
efficient,  it  must  he  properly  induced.  A  definite  technic  must  be 
followed.     Either  cocaine  or  stovaine  may  he  used,  the  latter  safer,  the 


Fig.  4. — Local  anesthesia;  method  of  introducing  needle.     (Veau.) 


'! 


r  slightly  more  active,  the  two  used  alike.     Having  determined 
tie  line  of  incision,  pinch  up  a  fold  of  skin  (Fig.  4),  introduce  the  needle 
at  one  end  of  the  line  and  push  it  into  the  skin,  but  not  through  the  skin. 
The  injection  is  intradermal  (Fig.  5).     As  the  needle  is  steadily  ad- 
vanced, the  syringe  is  emptied  slowly,  and  the  line  of  injection  is  in- 
licated  by  the  formation  of  a  wheal.     When  the  needle  has  entered 
length,  it  is  reintroduced  in  the  same  line  and  in  advance  of  the  pre- 
vncture,  hut  within  the  area  already  anesthetized.     In  this  way, 
!,,•„.  rst  puncture  is  felt.     When  the  line  of  incision  has  been  in- 

ter miii         i  this  manner  throughout  its  entire  length,  it  will   he  com- 
l  h<  '  sensitive  after  a  wait  of  one  to  two  minutes.     The  width  ^i 

1>:  of  anesthesia  will  depend  upon  the  rate' of  movement  of  the 

11. 1 .  through  the  skin  (Figs.  6,  7).     It  need  hardly  be  said  that  the 


ANESTHESIA. 


needle  and  solution  must  always  be  sterile.  It  is  better  to  pour  the 
solution  out  into  a  sterile  dish  or  glass,  rather  than  to  aspirate  it  from 
the  bottle.  The  air  must  be  forced  out  before  the  needle  is  introduced; 
care  must  be  taken  not  to  throw  the  injection  into  a  vein. 


Fig.    5. — Local   anesthesia;   the   needle   does   not   penetrate   the   whole 
thickness  of  skin;  "  intra  -dermic  "  injection.      (Veau.) 

When  an  area,  rather  than  a  line,  is  to  be  infiltrated,  in  a  case  where 
some  dissection  is  anticipated,  Schleich's  method  is  better,  in  which  the 
needle  is  plunged  directly  into  the  tissues  and  a  sufficient  quantity  of 


Fig.  6. — Local  anesthesia;  the 
zone  of  infiltration  is  narrow 
when  the  needle  is  pushed  for- 
ward and  emptied  rapidly. 
(Veau.) 


Fig.  7. — Local  anesthesia;  the 
zone  is  broad  when  the  needle  is 
introduced  slowly.      (Veau.) 


the  solution  discharged  to  raise  a  wheal.  The  needle  is  then  reintro- 
duced alongside  the  wheal  for  another  injection.  The  anesthesia  may 
be  renewed  from  time  to  time  during  the  operation. 


SCIILEIUl'S    SOLUTION'. 


19 


Si  hlei<  h's  formula  is  as  follows: 

NO.    I,   STRONG. 

Cocain.   Hydrochlor., 
Morphin.  Hydrochlor., 
S( "lii  Chloridi., 
Aq.  Destillat., 

NO.    2,    NORMAL. 

Cocain.    I  [ydrochlor., 
Morphin.  Hydrochlor., 
Sodii  Chloridi., 
Aq.  Destillat., 

NO.   3,    WEAK. 

Cocain.   Hydrochlor., 
Morphin.  Hydrochlor., 
Sodii  Chloridi., 
Aq.  Destillat., 


gr.  in. 
gr.    I 
gr.  in. 
3  iii,  3  iiss. 


gr.  iss. 
gr.    |. 

gr.  111. 

5  iiiss. 


gr.    ,'.. 

gr.  ,', 

gr.  in. 

o  iiiss. 


Two  or  three  drops  of  a  50  per  cent,  solution  of  carbolic  acid  may 
he  added  to  preserve.     The  solution  must  be  kept  cool.     Twenty-five 


Fig.  8. — The  finger  may  be  anes- 
thetized by  a  circular  injection  at  its 
base.     (Veau.) 


Fig.  9. — Complete  anesthesia  "i 
finger  induced  by  deep  injections  on 
each  side.  The  upper  and  lower 
needles  represent  the  primary  circular 
injection.     {Veau.) 


ayringefuls  of  Number  1,  fifty  syringefuls  of    Number  2,  and  500  of 
Number  3,  may  be  used  without  danger. 
The  patient  should  not  be  permitted  to  sit  up  during  the  anesthesia 


20  ANESTHESIA. 

if  cocaine  is  used,  for  it  exposes  him  to  the  risk  of  heart  failure.  It  is 
safer  to  keep  him  recumbent  for  a  half  hour  or  so  after  the  operation. 

If  a  finger  or  toe  is  to  be  amputated,  first  make  an  anesthetic  ring 
involving  the  skin  only  (Fig.  8),  and  follow  this  with  two  deep  lateral 
injections  to  obtund  the  main  nerve  trunks  (Fig.  9). 

Bier  has  lately  introduced  a  method  of  intravenous  anesthesia;  which, 
it  is  to  be  hoped,  will  prove  practical  in  the  hands  of  the  general  practi- 
tioner. Its  use  is  limited  to  operations  upon  the  extremities  and  this  is 
the  technic: 

The  limb  is  first  elevated  and  a  constrictor  applied  from  the  hand 
(or  foot)  upward.  The  limb  is  thus  emptied  of  blood.  A  tourni- 
quet is  next  tightly  applied,  one  above  and  one  below  the  proposed 
field  of  operation. 

The  principal  vein  is  next  exposed  in  the  distal  portion  of  the  field, 
the  incision  being  made  under  local  anesthesia  by  Schleich's  method. 
The  vein  once  exposed  is  opened,  a  cannula  introduced  and  50  to  100 
c.c.  novocaine  solution  injected  under  considerable  pressure.  In 
three  to  five  minutes  a  complete  local  anesthesia  is  produced.  At  the 
end  of  the  operation  the  solution  is  allowed  to  escape;  the  veins  are  then 
washed  out  with  normal  salt  solution  and  the  tourniquet  removed. 

The  technic  must  be  carefully  studied  before  attempting  the  pro- 
cedure. 

SPINAL  ANESTHESIA. 

Spinal  anesthesia  with  stovaine  can  only  very  rarely  be  of  use  to  the 
general  practitioner  in  emergency  work,  although  it  is  of  value  under 
certain  circumstances.  It  is  of  special  use  in  operations  involving  the 
anal  and  perineal  regions.  By  this  method  the  heart  and  lungs  are  not 
dangerously  affected.  It  is  a  solace  to  those  patients  whose  dread  of  a 
general  anesthesia  is  greater  than  their  dread  of  death,  and  who  will 
refuse  operations  of  absolute  necessity  rather  than  take  ether  or 
chloroform.  The  most  definite  contra-indication  is  uncertainty  of 
asepsis,  since  the  chief  danger  of  the  procedure  is  meningitis.  It 
should  not  be  used  in  the  young,  in  advanced  arterio-sclerosis,  in  cases 
of  septicemia,  or  central  nervous  disease.  The  average  duration  of  the 
analgesia  thus  produced  is  one  hour.     The  effects  are  fairly  uniform; 


SPINAL   ANESTHESIA.  21 

tin-  chief  after  effects  arc  headache  and  nausea.  One  of  the  author's 
patients,  operated  for  hernia  under  spinal  anesthesia  complained  for 

several  months  of  loss  of  sensation  in  the  penis  and  rectum,  though  not 
materially  interfering  with  the  functions  of  either.  The  preparation 
employed  by  the  author  is  that  of  ( 'ha put :  stovaine,  iogr. ;  sodii  l  hloridi, 
10  gr.;  distilled  water,  i  c.c.  This  is  put  up  in  hermetically  sealed  am- 
poules, each  containing  i  c.c.  of  the  solution,  which  is  sufficient  lor  an 
injection.  Bier  regards  cocaine  as  the  most  dangerous  and  tropaco- 
caine  the  safest,  and  this  latter  he  employs  in  doses  of  3/4  to  1  grain. 
The  syringe  employed  must  be  easily  sterilized  and  with  a  capacity  of 
at  least  2  c.c.  A  long  platinum  needle  is  best.  A  special  glass  syringe 
with  needle  for  this  injection  can  be  readily  secured. 

Technic. — The  patient's  back,  the  instruments,  the  solution,  the 
operator's  hands,  are  duly  prepared.  The  needle  is  attached  to  the 
syringe  and  the  contents  of  an  ampoule  aspirated  and  the  needle  de- 
tached. The  patient  sits  bending  forward  to  make  the  lumbar  spines 
more  prominent  and  to  enlarge  the  intervertebral  foramen  which  is  to 
be  traversed  by  the  needle.  Locate  the  iliac  crests  and  mark  their 
position  with  the  finger  nails.  The  line  connecting  the  highest  points 
of  the  iliac  crests  intersects  the  fourth  lumbar  spine  which  is  next  to  be 
located  in  the  middle  line.  The  next  spine  above  is  marked  and  be- 
tween these  two  points  the  puncture  is  made.  Hold  the  left  index 
finger  on  the  third  lumbar  spine.  Hold  the  unattached  needle  in  the 
right  hand,  and  enter  its  point  just  below  the  third  lumbar  spine  a  little 
to  the  right  of  the  middle  line,  and  push  it  slightly  upward  and  inward  at 
an  angle  sufficient  to  meet  the  spinal  membranes  in  the  middle  line. 
Tushing  the  needle  steadily  upward  and  inward  it  can  be  felt  to  reach 
the  resisting  ligamentum  subflava  and  finally  the  puncture  of  tin- 
membranes  is  announced  by  the  (low  of  spinal  fluid  from  the  needle. 
Hold  the  finger  over  the  outlet  until  the  syringe  can  be  attached;  then 
let  sufficient  fluid  run  in  the  syringe  to  make  2  c.c;  in  other  words, 
make  a  mixture  in  the  syringe  containing  equal  parts  of  stovaine  solu- 
tion and  spinal  fluid.  The  clear  spinal  tluid  becomes  milky  on  meet- 
ing the  anesthetic  solution.      Now  slowly  inject  the  mixture,  and  when 

the  syringe  is  emptied,  withdraw  the  needle  with  a  rapid  movement  ami 
seal  the  puncture  with  collodion.     It  will  require  no  further  attention. 


2  2  ANESTHESIA. 

Have  the  patient  lie  down  and  now  prepare  for  the  operation.  In 
ten  to  fifteen  minutes  the  anesthesia  begins.  The  patient  complains 
of  a  pricking  sensation  in  the  feet  and  numbness  in  the  legs.  A  pinch 
or  a  pin  prick  will  be  felt  but  will  not  be  painful.  If  the  pain  becomes 
too  severe  in  the  course  of  the  operation,  a  little  chloroform  or  ether  can 
be  employed.  If  the  anesthetic  zone  does  not  extend  high  enough,  in- 
cline the  body  slightly,  head  downward.  During  the  operation  the 
patient's  face  is  tikely  to  be  congested  and  his  head  will  throb.  After- 
ward there  is  likely  to  be  a  severe  headache  for  a  little  while  and  per- 
haps some  nausea. 

The  site  of  puncture  may  be  numbed  with  cocaine,  so  that  the 
spinal  injection  is  painless.  If  the  point  of  the  needle  engages  against 
the  vertebra,  withdraw  slightly  and  change  the  direction  as  the  judg- 
ment dictates.  The  most  common  mistake  is  in  directing  the  needle 
too  much  upward.  Only  very  rarely  will  one  fail  to  reach  the  spinal 
canal  if  the  landmarks  are  well  defined. 

Hollander  (Deutsche  Med.  Woch.  schr.,  Jan.  14,  1909)  protests 
against  the  way  in  which  many  surgeons  are  turning  away  from  spinal 
anesthesia  and  indicates  the  many  advantages  of  the  method.  One  of 
his  chief  arguments  in  its  favor  is  its  prevention  of  post-operative  paral- 
ysis of  the  bowel  in  abdominal  work.  He  mentions  60  operations  of 
this  class,  including  the  appendix,  stomach,  pancreas,  kidney,  gall- 
bladder and  uterus  operated  under  spinal  anesthesia,  all  of  which 
promptly  recovered. 

Jonnesco  reports  most  favorable  results  with  the  stovaine  modified 
by  the  addition  of  strychnia.  He  does  not  hesitate  to  puncture  the 
cord  at  the  cervico-dorsal  juncture.  Under  spinal  anesthesia  he 
performs  operations  on  every  part  of  the  body  (Pr.  Medical,  Oct.  13, 
1909). 


CHAPTER   [V. 

SUTURES;  METHODS,  AND  MATERIALS. 

Sutures  arc  applied  with  a  view  to  maintaining  the  coaptation  of 

divided  structures.  This  is  necessary  to  facilitate  repair  and  re-tore 
function.  Suturing  serves  the  additional  purpose  of  <  he<  king  hemor 
rhage  from  the  smaller  vessels.  There  is  no  part  <>i"  the  surgi 
technic  that  deserves  more  attention  than  the  selection  and  use  of 
sutures.  It  is  of  special  importance  to  the  emergency  surgeon  who 
faces  infection  in  every  direction.  His  suturing,  however,  he  may 
absolutely  control  and  make  aseptic,  and  this  may  be  the  only  different  e 
between  success  and  failure. 

Various  materials  are  used,  some  quite  commonly,  other-  rarely 
and  for  a  certain  purpose;  catgut,  silk,  silkworm  gut,  silver  wire,  kan- 
garoo tendon,  and  horsehair.  The  three  first  named  will  inert  all  the 
requirements  of  the  emergency  surgeon. 

No  material  is  available  which  does  not  have  a  certain  strength  and 
which  cannot  be  made  aseptic.  For  emergency  work,  these  materials 
must  be  already  prepared.  The  creation  of  a  proper  suture  from  the 
raw  material  is  a  matter  of  time  and  care. 

The  general  practitioner  will  do  better  to  buy  his  sutures  put  up  it 
form  available  for  immediate  use,  being  first  assured  that  they  come 
from  a  reliable  source  and  are  put  up  in  a  manner  to  keep  them  Sterile. 
Much  suture  material  on  the  market  has  neither  of  these  qualifi<  ations. 
Silk  has  the  advantage  of  lending  itself  t<>  emergency  sterilization  by 
boiling  and  immersion  in  an  antiseptic  solution,  nor  i-  it  readily  « 
taminated  when  once  sterile;  but  it  should  not  be  boiled   in 
lution,  which  makes  it  brittle.      It  has  the  disadvantage  of  not 
absorbable.      It    may   be   used    in    buried   sutures,    but    it- 
in  that  respect  grows  more  and  more  limited  as  the  art  i 
and  preservation  of  catgut  improve-.      It  may  be  used  in  interr 

2-> 


24  SUTURES,  METHODS  AND  MATERIALS. 

skin  sutures,  suture  of  nerves,  of  tendon,  and  of  the  intestine,  but 
muscular  tissues  do  not  tolerate  it. 

Catgut  is  the  ideal  material  for  the  buried  suture.  The  chromicized 
gut  has  ample  strength  and  is  so  prepared  as  to  resist  absorption  in 
a  certain  tissue  for  a  certain  time;  but  it  should  be  remembered  that 
occasionally  chromicized  gut  becomes  practically  unabsorbable  and, 
acting  as  a  foreign  body,  gives  rise  to  persistent  sinuses.  With  a  little 
attention  to  this  detail,  a  suture  may  be  selected  which  will  resist  ab- 
sorption until  repair  is  complete.  Plain  catgut  can  be  used  in  those 
tissues  only  which  rapidly  unite.  It  is  ideal  for  suturing  the  peritoneum 
and  for  ligating  vessels  except  the  very  large  ones.  It  is  very  easily  con- 
taminated. It  should  never  be  used  where  there  is  pus  as  a  buried 
suture.  The  three  qualities  which  catgut  for  suturing  must  possess  are: 
sterility,  tensile  strength,  and  absorbability.  If  a  certain  brand  of 
catgut  produces  stitch-abscess  persistently;  if,  properly  used,  it  still 
breaks  inopportunely;  if  it  refuses  to  be  absorbed,  then  there  is  some- 
thing wrong  with  its  manufacture.  The  occasional  surgeon  Lacking 
opportunity  to  test  all  the  brands,  must  therefore  fall  back  upon  the 
manufacturers  reputation  and  guarantee. 

Silkworm-gut  is  very  strong,  non-elastic,  uon-absorbable,  readily 
sterilized,  and  is  much  employed  where  the  wound  is  large  and  deep 
and  the  tissues  tend  strongly  to  spread  apart.  Most  surgeons  employ 
it  to  suture  the  skin  and  fascia  after  laparotomy. 

The  pagenstecher  celluloid  linen  is  in  high  favor  with  some  surgeons; 
it  is  more  flexible  than  silkworm-gut  and  absorbs  moisture  without 
softening. 

The  methods  of  suturing  adapted  to  emergency  surgery  are  the 
interrupted  suture  and  the  continuous  suture.  Others  occasionally  em- 
ployed in  general  surgery  are  the  quilled,  the  quilted  (Fig.  10),  the 
twisted,  and  the  button  sutures. 

The  continuous  suture  is  used  in  aseptic  wounds  only.  Therefore, 
accidental  wounds  will  only,  on  rare  occasions,  permit  its  employment. 
It  has  the  advantage  of  being  very  rapidly  applied,  but  is  less  sure  than 
the  interrupted  suture.  A  little  practice  is  essential,  for  it  is  not  al- 
together easy.     Its  success  depends  largely  upon  the  assistant. 

This  is  the  mode  of  making  the  continuous  suture:  Commence  by 


THE    CONTINUOUS    SUTURE. 


25 


The  quilted  suture. 
(Moullin.) 


passing  the  suture  at  the  upper  angle  of   the  wound.     Make   three 

successive  knots.     Two  are  sufficient  for  catgut.     The  short  thread  is 

caught  in  forceps  and  retained  till  the  suture  is  completed,  at  whi<  h 

time  it  is  cut  off  close  to  the  knot  (Fig.  11). 
The     needle    traverses,    successively    and 

obliquely,  first  the  one  lip  of  the  wound  and 

then  the  other;  each  time  the  assistant  seizes 

the    thread  at  the  point  of  emergence,  and 

holds  it  tightly  until  the  surgeon  makes  a  new 

point  of  emergence,  when  the  assistant  takes 

a  new  hold.     In  this  manner,  the  tension  of 

the  suture  is  made  absolutely  uniform. 

The  mode  of  arrest  of  the  continuous  suture  fig 

is  important.     In  making  the  terminal  knot, 

the  suture  must  not  be  allowed  to  relax.     To  accomplish  this,  the 

surgeon  slips  the  index  finger  in  the  last  loop  instead  of  pulling  the 

thread  all  the  way  through,  as  was  done 
with  all  the  others.  Traction  with  this 
finger  holds  the  line  of  suture  tight  while 
the  terminal  thread  on  the  one  side  is 
knotted  three  times  with  this  loop  on  the 
other  side  (Figs.  12,  13). 

If  the  continuous  suture  is  long,  its 
stability  is  insured  by  crossing  the  threads 
at  the  middle  of  the  line  of  suture  (Fig.  14). 
The  suture  is  thus  interrupted  at  its  mid- 
dle in  this  manner:  the  needle  is  simply 
passed  back  under  the  last  loop,  at  the 
time  care  being  taken  that  the  suture  does 
not   slip.      The   succeeding  steps  are  the 

"Me^iof  TSLt  same  as  before  (Fi§s-  J5>  l6)-    The  suturo 


Assistant 

holding  the  suture  tight  while  the  completed,  the  loose  ends  are  cut  off  close 

needle  is  passed  again.      ( v  eau.)  r  > 

to  the  knot. 
The  interrupted  suture  is  generally  employed  in  suturing  the  skin, 
and  may  be  of  silk,  silkworm-gut,  silver,  etc.     It  must  not  be  absorb 
able.     These  sutures  may  be  placed  deeply  or  superficially,  in  the  one 


26 


sutures;  methods,  and  materials. 


Pip.  1 2. — Completing  the 
continuous  suture;  holding 
the  suture  tinht  with  finger 
through  loop  whili    . 
ready  to  tie. 


Pio.  ii.  —Method  "f  ty- 
ing compute']  continuous 
suture.      (  I  ■ 


Fig.  14. — Continuous  su- 
ture interrupted  in  its  course 
(Hartmann.) 


Fig.  15. — Method  of 
interrupting  the  con- 
tinuous suture  in  its 
course.  Needle  passed 
back  under  last  loop. 
(Veau.) 


Fig.  16.— The 
needle  has  been 
passed  through  the 
loop  which  is  drawn 
down  tight  and  the 
suture  proceeds  as 
before.     (Veau.) 


Fig.  17. — Method  of  passing  deep  inter- 
rupted sutures.     (Veau.) 


THE    INTERRUPTED    SUTURE. 


27 


case  where  there  is  much  tension,  in  the  other  for  mere  approximation. 

The  deep  sutures  are  placed  two  or  three  centimeters  apart. 

.    The  needle  is  entered  one  centimeter  from  the  edge  and  emerges 


Fig.  18. — Tying  interrupted  sutures. 
Forceps  everting  lips  of  wound  to  se- 
cure coaptation.     (Veau.) 


Fig.    19. — Method   of  passing 
superficial  sutures.     {Veau.) 


the  same  distance  from  the  other  side.  The  thread  is  concealed 
through  most  of  its  extent  (Fig.  17).  None  is  tied  until  all  are  passed. 
The  lips  of  the  wound  are  brought  to- 
gether as  the  knots  are  tied.    (Fig.  18). 

A  few  superficial  catgut  sutures  may 
be  necessary  if  the  deep  sutures  do  not 
completely  approximate.  They  are 
passed  through  the  thickness  of  the 
skin  alone  and  very  close  to  the  edge 
of  the  wound  (Fig.  19). 

No  knot  should  be  drawn  too  tight. 
It  may  interrupt  the  circulation  and 
defeat  repair.  The  knot  should  be 
made  to  one  side  of,  and  not  over  the 
wound  (Fig.  20). 

If  all  goes  well,  the  sutures  may  be  removed  toward  the  eighth  day. 
Remaining  too  long,  they  favor  infection. 


Fig. 


Hou  to  do  it. 


Hon  not  to  do  it> 


20. — Sutures  must  not  be  tied 
too  tight.     (Moidlin.) 


28 


sutures;  methods,  and  materials. 


Method  of  Removing  Sutures. — Seize  the  loop  with  a  dissecting  forceps 
held  in  the  left  hand.  With  a  pointed  scissors  divide  the  thread  close 
to  the  skin,  being  careful  not  to  cut  between  the  knot  and  the  forceps, 
else  one  will  be  trying  to  pull  the  knot  through  the  skin. 

Suppose,  in  spite  of  care,  infection  occurs.  The  temperature  reaches 
ioo  1/  2°  on  the  following  day.  On  the  second  day  following,  it  is  a 
little  higher.  Upon  removal  of  the  dressing,  the  skin  around  the 
wound  is  found  to  be  reddened  and  swollen.  Re- 
move two  or  three  of  the  middle  sutures  at  once. 
Secure  drainage  and  use  a  wet  dressing.  This 
will  usually  check  the  infective  process  and  pus 
formation. 

The  subcuticular  suture  is  of  great  service  in 
aseptic  operative  wounds,  wherever  it  is  especially 
desired  to  prevent  a  scar.  It  is  made  in  this 
manner: 

Introduce  a  small  needle  threaded  with  catgut, 
one-fourth  inch  above  the  upper  angle  of  the 
wound,  and  let  it  penetrate  the  skin  and  emerge 
exactly  at  the  upper  angle.  It  next  penetrates 
the  face  of  the  skin  incision,  taking  a  bite  first  on 
one  side  and  then  on  the  other  exactly  opposite 
method  of  passing  and  (Fig-  21).  At  the  end,  the  needle  traverses  the 
skin  at  the  lower  angle  of  the  wound  in  the  same 
manner  as  it  entered  at  the  upper  angle;  the  sutures  are  then  tightened 
(Fig.  22)  until  the  edges  of  the  wound  are  exactly  coapted.  The  ends 
are  secured  from  slipping  either  by  knots  or  by  pasting  them  down 
with  collodion  or  adhesive  plaster.  If  the  thread  is  not  absorbed,  it 
may  be  removed  about  the  sixth  day  by  clipping  one  end  close  to  the 
skin  and  then  gently  drawing  it  from  the  other  end. 

Cannaday  (J.  A.  M.  A.,  Jan.  4,  1908)  uses  pagenstecher  linen  and 
after  starting  the  suture  secures  the  loose  end  by  a  half  bow  knot.  The 
terminal  thread  is  secured  in  the  same  way  and  slipping  or  loosening  is 
thus  prevented. 


Fig.  21.  Fig.  22. 

The  subcuticular  suture; 


CHAP!  l.k  V. 
DRAINAGE. 

Drainage  may  justly  be  regarded   as  a   matter  of  antisep  I 

prevents  sepsis  by  creating  a  current  which  moves  away  from  the  wound, 

and  by  depriving  the  bacteria  of  their  chief  pabulum— tl 
dates.     Drainage  facilitates  repair  by  relieving  tension.     In  the 
manner  it  relieves  pain.     But  when  these  points  arc  made  I 
is  said,  for  drainage  is  by  no  means  an  unmixed  good.     <  >n  the 
trarv,  it  is  a  necessary  evil  and  for  these  reasons:  in  reality  il 
foreign  body;  it  necessitates  frequent  renewal  of  dressings;  it  may  injure 
granulations;  it  keeps  the  wound  open  and  delays  healing;  in  the 
abdominal  cavity  it  sometimes  predisposes  t<>  fistula,   hernia, 
intestinal  obstruction.     Nor  is  the  profession  by  any  mean-  >>i  one 
mind  regarding  the  indications  and  contra-indications.     It  is  a  matter 
in  which  one  cannot  be  dogmatic.     The  rule  of  practice   mu 
necessity  vary  with  the  patient,  the  operator,  and  the  environment. 

The  emergency  surgeon,  the  general  practitioner,  will   more  often 
drain  than  the  hospital  surgeon  in  formal  operatioi  V 

to  the  fundamental  principles  involved. 

Aseptic  wounds,  as  a  rule,  do  not  require  drain... 

Infected  wounds  or  those  suspected  should  always  he  drained 
infection  of  any  kind  demands  an  outlet. 

Accidental  wounds  are  presumed  to  la-  infected,  whei 
wounds  are  presumed  to  be  aseptic. 

A-  an  ex.  eption  to  the  rule  that  aseptic  wounds  do  nol 
age,  note  that  those  in  which  there  is  of  necessity  much 
oozing  do  better  with   temporary   drain 
putation  stumps,  and  breast  amputations. 

Suspected  wounds  are  not  drained  after  the  third 
has  not  made  its  appearance  n<>r  seems  likely  to  .!■ 

20 


30  DRAINAGE. 

Infections  are  drained  as  long  as  there  are  any  discharges. 

The  means  of  drainage  in  emergency  practice  are  three:  tubes,  gauze, 
and  open  wounds;  or  combinations  of  the  three. 

Rubber  tubes,  the  larger  the  better  in  proportion  to  the  infected  cavity, 
are  the  best  means  of  draining  large  cavities,  and  are  the  sole  means 
of  draining  abscess  cavities  and  large  infections.  They  should  be 
fenestrated,  and  may  be  improvised  from  rubber  catheters.  Wherever 
used,  they  must  be  cut  off  close  to  the  surface  and,  in  the  case  of  cavities, 
must  be  anchored  by  suture  or  safety  pins. 

Gauze. — Plain  sterile  gauze,  which  drains  by  capillarity,  is  an  effi- 
cient means  of  removing  exudates,  such  as  serum  and  blood.  It  has 
the  additional  advantage  that  in  appropriate  cases  it  may  be  at  the 
same  time  employed  for  hemostasis.  It  has  the  disadvantage  that  it 
soon  ceases  to  drain,  acquires  adhesions,  and  is  painful  to  remove. 

Tubal  and  capillary  drainage  are  advantageously  combined  in  the 
"gauze  wick"  and  "cigarette  drain."  A  "gauze  wick"  drain  is  made 
by  splitting  a  tube  of  the  required  length  and  fitting  it  loosely  with  a 
strip  of  gauze.  When  the  tube  is  carried  to  the  bottom  of  the  cavity, 
the  projecting  gauze  is  brought  in  contact  with  the  oozing  surface,  is 
hemostatic,  and  finally  may  be  removed  without  disturbing  the  tube. 
A  cigarette  drain  acts  on  the  same  principle  and  is  essentially  a  series 
of  wick  drains,  one  within  the  other.  To  make  a  "cigarette  drain," 
take  a  ten  inch  square  of  rubber  tissue,  cover  it  with  four  or  five 
layers  of  sterile  gauze,  and  roll  the  whole  into  a  slender  cylinder. 

"Wick"  and  "cigarette"  drains  should  be  removed  on  the  second 
or  third  day.  If  infection  is  present  at  that  time,  a  tube  should  be  sub- 
stituted; a  tube  must  be  employed  if  infection  develops  later.  Tubes 
employed  in  the  drainage  of  pus  cavities  should  be  removed,  cleaned, 
and  reinserted  at  least  every  third  day,  and  are  to  be  shortened  pari 
passu  with  granular  repair. 

As  has  been  said,  an  open  wound  is  a  means  of  drainage,  and  for 
that  reason  accidental  incised  wounds  are,  as  a  rule,  not  completely 
sutured.  Lacerated  wounds  not  reparable  need  no  other  drainage  than 
that  afforded  by  the  gauze  dressings. 

To  note  briefly  some  examples  of  drainage:  Abscesses  are  always 
to  be  drained  with  tubes. 


DRAINAC1 . 


Acute  spreading  infections  are  to  be  drained  with  tul 

Accidental  incised  wounds  are  to  be  drained  with  tul  mply 

by  rubber  tissue  if  the  wound  i^  small. 

Operative  wounds  of  the  soft  parts  in  emergency  practice  are  i 
best  drained  superficially — all  the  Layers  are  completely  dost 
the  skin.     A  few  strands  of  catgut  between  the  li|»  of  the  wound  will 
often  he  all  that  is  necessary  for  drainage  and  has  the  adv. int.. 
requiring  no  change  of  dressing. 

An  empyema  or  purulent  peritonitis  must  be  drained  with  I 

Many  thoracic  and  abdominal  conditions  are  to  be  drained  with  the 
wick  or  cigarette  drain.  If  there  is  no  probability  of  infection,  if 
there  is  not  much  oozing,  do  not  drain  at  all. 

In  compound  fractures  and  compound  dislocations  drain  only  the 
skin  wound.     If  infection  develops,  deep  drainage  must  be  substituted. 

Further  details  will  he  given  in  connection  with  the  various  operations 
requiring  drainage. 


CHAPTER  VI. 
DRESSINGS,  BANDAGES,  SPLINTS. 

The  emergency  surgeon  needs  no  great  variety  of  dressing  materials. 
If  he  has  sterile  gauze  and  sterile  absorbent  cotton,  he  can  efficiently 
meet  all  the  indications  so  far  as  dressings  are  concerned;  for  these 
materials  furnish  in  the  highest  degree  the  properties  which  pertain 
to  a  good  dressing.  A  good  dressing  is  sterile,  absorbent,  and  pro- 
tective. It  need  be  nothing  more;  it  must  be  that.  For  emergency 
work  it  is  better  to  buy  these  materials  already  prepared  and  ready  for 
instant  use.  But  they  must  come  from  a  reliable  source.  Even  the 
most  trustworthy  products  are  not  always  aseptic.  In  major  oper- 
ations they  should  be  re-sterilized  if  possible.  Of  course  the  surest  way 
to  sterilize  is  by  steam.  Still  these  materials  exposed  to  the  high  heat  in 
the  closed  oven  of  the  kitchen  stove  might  reasonably  be  expected  to 
be  germ  free.  Medicated  gauze  is  often  useful  but  not  essential,  nor 
so  much  employed  as  formerly.  It  may  be  improvised  by  dusting 
the  plain  sterile  gauze  with  the  preferred  antiseptic  powder  at  the 
time  of  dressing.  For  that  matter  all  of  the  dressing  may  be  impro- 
vised for  temporary  use  from  muslin,  linen,  or  cheesecloth.  Towels 
or  sheets  may  be  prepared  by  boiling  for  fifteen  minutes  in  soda  solu- 
tion, rinsing  in  cold  sterile  water,  wringing  out  the  water,  and  com- 
pleting the  drying  process  on  the  stove.  From  these  materials  one 
may  provide  not  only  dressings,  but  compresses  and  sponges  for  the 
operation. 

An  aseptic  wound  requires  that  the  dressing  be  dry;  whatever  slight 
serous  oozing  there  may  be  is  thus  rapidly  absorbed. 

Septic  wounds  require  a  dressing  moist  with  some  antiseptic  solution. 
For  one  thing,  the  moist  gauze  conforms  better  to  the  irregularities 
of  a  lacerated  wound.  Again,  the  antiseptic  agent  exerts  some  slight 
destructive  effect,  perhaps,  upon  the  germ  already  in  the  wound  and 

32 


OKI   S 


is  a  more  effective  si  reen  against  those  trying  to  gel  in.     M 
and  bichloride  gauze  are  the  mosl  commonly  used.     I 
present,  sterile.'  gauze  saturated  with  peroxide  of  hydi 
recommended. 

The  dressings  must  be  ample.     Too  often  an  aseptic  operative  wound 
eventually  becomes  infected  merely  because  not  sufficiently  : 
The  dressings  must  not  only  be  thick  enough,  but  they  mu 
widely  beyond  the  limits  of  the  wound.     It  is  a  poordn 
if  one  can  lift  its  edges  and  inspect  the  wound. 

The  frequency  of  redressing  is  variable.     In  general,  the  fewer  dj 
ings  the  better.     The  aseptic  operative  wound  should  need  but 
dressings.     The  original  dressing  is  removed   when  ti 
taken  out  on  the  eighth  to  the  tenth  day. 

The  septic  wound  may  need  to  lie  dressed  daily.     A  wound  | 
ably  infected  but  not  septic,  one  in  which  a  drainage  tube  was  used, 
will  need  to  be  dressed  on  the  second  to  the  fifth  day,  when  the  drain 
age  tube  is  removed.     The  frequency  of  dressing  thereafter  will  de- 
pend upon  the  degree  of  sepsis.     In  changing  the  dressing  of  a  sterile 
wound,  every  precaution   must  be  taken   against  infection.     Many  a 
fine  operative  result  is  spoiled  by  carelessness  in  changing  the  dress 
The  hands,  the  solutions,  the  instruments,  must  be  prepared. 

It  is  good  practice  in  the  case  of  any  kind  of  wound  to  change  tin- 
dressing  whenever  soiled,  for  sterile  exudates  may  become  good  cul- 
ture  media.      One   may,    however,    follow   Semi's  suggestion,   dus 
the  saturated  area  with  boro-salicylic  acid  or  other  anitseptic  powder 
and  covering  with  an  additional  layer  of  cotton  and  band 

Pain  or  rise  of  temperature  after  the  first  twenty  four  h<>::r>  is 
an   indication   to   change   the   dressing   ami    inspect    the   wound.     A 
loosened  dressing  calls  for  renewal.     The  dressing  that  slips  or  rub<. 
is  a  very  poor  one.     When  the  dressings  are  adherent  to  the  wound 
face,  they  are  to  be  saturated  with  warm  sterile  water  or  with  pen 
of  hydrogen.     The  latter  is  excellent  when  the  dressing  com 
blood.      When   changing   the  dressings   any   undue   movement  ol    the 
parts  must  be  avoided.     The  principles  of  support  and  fund 
rest  are  not  to  be  neglected  even  for  the  <hort  time  the  dres 


34 


DRESSINGS,    BANDAGES,    SPLINTS. 


BANDAGES. 

The  gauze  roller  is  porous,  absorbent,  protective,  and  therefore  a 
part  of  the  dressing.  The  wound  is  covered  with  gauze,  the  gauze 
is  amply  covered  with  absorbent  cotton,  and  the  whole  retained  by  a 
smooth  bandage,  uniformly  compressive.  Bandaging,  as  the  older 
doctors  knew  it,  is  almost  a  lost  art,  for  the  gauze  roller  is  accommo- 


Fig.  23. — Double  spicse  of  groin.      {Heath.) 

dating  and  adhesive  plaster  convenient.  One  may  give  a  dressing  the 
appearance  of  stability  without  its  being  in  reality  efficient.  The 
bandage  must  be  so  applied  that  it  will  not  slip  and  will  remain  closed 
at  either  end.  It  must  extend  well  beyond  the  limits  of  the  subjacent 
dressing,  and  in  the  case  of  the  limbs  must  reach  beyond  the  next 
joint  above.  For  example:  a  dressing  of  the  foot  must  extend  above 
the  ankle;  of  the  leg,  above  the  knee;  of  the  forearm,  above  the  elbow. 
In  the  region  of  the  groin  a  double  spica  should  be  employed,  extend- 
ing well  up  over  the  abdomen,  and  down  over  the  thighs  (Fig.  23). 


K3   l I   01     MTi  \  i\(.    \    BAN1 


A  bandage  of  the  neck,  that  ii  may  nol  slip,  must  include  the 
and  shoulder. 

The  dressings  of  the  abdomen  and  thorax  are  besl  held  in  plao 
wide  bands  of  flannel  firmly  applied  and  secured  by  safet)  pin 
whose  edges  are  held  down  by  suspenders  and  perineal  strips. 

To  apply  a  bandage  to  a  limb,  For  example:  stand  in  front  of  the 
patient.     That   the  bandage  may  unroll   more  freely,  place  the  free 
end  of  the  bandage  in  contacl  with  the  dressing  by  its 
and  hold  the  roller  to  the  outside  of  the  limb— in  the  right  hand  for 
the  left  limb,  in  the  left  hand  for  the  righl  limb.     Each  turn  should 
overlap  about  one-half    the    previous   turn.     To   maintain   uniform 
pressure  in  spite  of  the  limb's  change  in  contour  as  the  bai 
progresses,  certain  modifications  of  the  ordinary  spiral  or  circular 
turns  are  necessary — the  "spiral  reverse"  and  ' 'figure-of-eight 
to  be  employed.     The  "spiral  reverse"  is  used  when-  the  i  in  umfei 
rapidly  changes,  as  in  approaching  the  calf  of  the  leg;  if  it  i-  not  made, 
one  edge  of  the  bandage  is  tight  and  the  other  edge  loose.     To  make 
the  reverse,  the  bandage  is  slackened  when  the  outer  side  of  the  lim!> 
is  reached  and  a  half  rotation  is  made,  by  a  twist  of  the  wrist.     The 
beginner  is  often  observed  to  make  a  complete  turn  of  the  ban 
instead  of  a  half  turn.     This  tightens  the  bandage,  but  does  nol 
uniform   compression.     In   making  the  turn,  the  thumb  of  one  hand 
steadies  the  lower  edge  of  the  bandage,  while  the  Other  hand    n 
the  half    turn   mentioned.     The  reverse  should  always  be  made   in 
the  same   vertical  line  and  should,   if  practical,  correspond   to  the 
wound,   in  order  to  give  it  the  advantage  of  the  extra  thickm 
The  bandage  is  then  continued  on  around  the  leg  until  the  outside  is 
again  reached  when  the  reverse  is  repeated.     The  "figure-of-eight," 
the  second  means  of  taking  up  the  sla<  k,  is  most  useful  in  the  n 
of  the  joints,  and  at  the  calf. 

Bandage  for  the  Foot. — (Fig.  24.)     Begin  near  the  toes 
turns,  reversed  as  the  ankle  is  neared.      Encircle  the  ankle  with   the 
"figure-of-eight"  turns  and  continue  the  spiral  turns  up  th< 
is  desired  to  cover  the  heel,  the  firsl  turn  should  cross  the  upper 
of  the  heel  and  over  the  Front  of  the  joint;  the  second  tun 
the  lower  half  of  the  first;  the  third  turn  overlaps  the  uppei 


36 


DRESSINGS,    BANDAGES,    SPLINTS. 


first.     The  roller  on  the  third  turn  reaches  the  dorsum  of  the  foot,  and 
is  carried  obliquely  across  toward  the  little  toe  and  the  foot  is  covered 


Fig.  24. — Bandage  of  foot.     {Heath.) 


Fig.    25. — Bandage  of  foot.     Heel  covered. 
(Heath.) 


by  spiral  turns  which  progress  upward,  or  it  may  be  applied  as  indi- 
cated in  Fig.  25.  The  spica  of  the  foot  is  indicated  by  Fig.  26. 
If  it  is  desired  to  cover  the  toes,  back  and  forth  folds  extending  from 


Fig.  26. — Spica  of  foot.     (Stewart.) 


in  front  of  the  ankle  to  a  corresponding  point  on  the  sole  may  be  run  on 
and  held  in  place  by  additional  circular  turns  about  the  foot. 

Bandage  for  the  Leg. — Begin  above  the  ankle  with  spiral  turns,  pro- 


BANDAG]     POB    mi     i  i  ,.    \n,, 


Fig.  27.  Pic.  18. 

Bandage  of  leg. 


Fie.  29. — Figure  ofi"S"  of  knee. 
(Heath.) 


38 


DRESSINGS,    BANDAGES     SPLINTS. 


gress  upward  and,  as  the  calf  is  approached,  use  the  reverse  (Fig.  27); 
or  a  "figure-of-eight"  may  be  employed  throughout  (Fig.  28),  but  the 
latter  does  not  fit  so  well  about  the  calf  as  the  former. 

Bandage  for  the  Knee. — This  may  be  a  continuation  of  the  leg  band- 
age or  may  include  the  knee  alone;  in  either  case  it  is  a  "figure-of-eight" 
running  from  below  the  patella  around  the  outer  side  of  the  knee, 
across  and  up  behind  the  knee  to  the  inner  condyle.  Now  make  cir- 
cular turns  about  the  thigh.     From  the  inner  condyle,  cross  the  knee 


Fig.  31. — Spica  of  groin.      {Heath.) 


obliquely  downward  and  outward  to  the  head  of  the  fibula;  make 
a  circular  turn  about  the  leg  below  the  knee,  and,  when  the  patellar  line 
is  reached,  begin  over  again  the  "figure-of-eight,"  lapping  the  preced- 
ing one  (Figs.  29,  30). 

Bandage  for  the  Groin. — Begin  at  the  inner  end  of  the  groin  and  carry 
the  roller  upward  and  outward  to  the  iliac  crest,  around  to  the  opposite 
crest,  obliquely  across  the  belly  toward  the  pubes,  around  the  thigh 
to  the  starting-point.  Repeat  these  turns  as  often  as  necessary,  each 
overlapping  the  preceding  (Fig.  31). 


BANDAGES    POH     1 1 1 1     BR KAST . 


Pic.  j!2. — Bandage  for  breast.     (//• 


Pig.  .;.(. — Bandage  for  both  bn 


40 


DRESSINGS,    BANDAGES,    SPLINTS. 


The  Double  Spica. — The  right  groin  is  bandaged  as  described  above. 
When  the  roller,  carried  about  the  body,  reaches  the  left  side  of  the 
pelvis,  it  leaves  the  original  track,  follows  the  left  groin  downward  and 


Fig.  34. — Finger  bandage. 
{Heath.) 


Fig.  35. — Spica  of  the  thumb. 
{Heath.) 


thence  around  the  thigh;  is  then  carried  across  the  belly  and  around 
the  body  to  the  right  groin  again.  These  bandages  may  be  applied 
with  the  patient  standing  or  with  the  pelvis  on  the  Volkman  rest. 


Fig.  36. — Bandage  for  all  the  fingers.     {Heath.) 


For  the  perineum  and  pelvis,  one  may  use  the  "St.  Andrew's  cross," 
which,  after  a  turn  about  the  body,  crosses  over  the  left  groin,  behind 
the  left  thigh  just  below  the  nates,  obliquely  upward  across  the  peri- 


BANDAG1     POB    THUMB. 


ncum,  over  the  right  groin  toward  the  right  iliac  spine.     It  th< 
around  the  left  iliac  spine  and  down  the  Left  groin  a<  rosa  the 
Bandage  for  the  Breast.-    Begin  with  two  <>r  three  turns  about 

chest;  carry  the  roller  across  the  breast  to  the  sound  side; 

it  under  the  affected  breast  to  the  opposite  shoulder;  across  1  k  to 

the  breast  again  and  up  over  the  shoulder;  and  then  around  the 
again  (Fig.  32).     Both  breasts  may  l>e  bandaged  at  tin-  same  time, 
carrying  the  turns  about  first  one  breast  and  then  the  Other    I    . 


Fig.  37. — Bandage  for  arm.     (//. 

Bandage  for  the  Finger. — Begin  with  two  or  three  turns  about  the 
wrist,  and  then  carry  the  bandage  across  the  dorsum  of  the  hand 
base  of  finger,  and  run  it  down  to  the  tip  by  two  or  three  oblique  I 
bandage  from  the  tip  to  the  base  by  regular  circular  turn-.     From  the 
base,  carry  die  bandage  across  the  dorsum  of  the  hand  and  around  the 
wrist  again  (Fig.  34). 

Bandage  for  the  Thumb. — Begin  at  the  ulnar  side  of  the 
carry  the  bandage  across  the  dorsum  around  the  wrist  for 


42 


DRESSINGS,    BANDAGES,    SPLINTS. 


Next  carry  the  roller  obliquely  across  the  dorsum  of  the  hand  and 
toward  the  radial  side  of  the  thumb,  as  near  the  tip  as  desired.  Secure 
by  a  circular  turn  and  then  carry  the  roller  back  to,  and  around,  the 
wrist  again  and  so  proceed,  progressing  toward  the  base  of  the  thumb 
(Fig.  35).     Bandage  for  all  the  fingers  and  thumb,  see  Fig.  36. 

Bandage  for  the  Hand  and  Arm. — Begin  with  circular  turns  around 
the  wrist  and  then  carry  "figure-of-eight"  about  the  wrist  and  hand; 
finish  with  spiral  turns  progressing  up  the  arm  (Fig.  37). 

Spicafor  the  Shoulder. — Begin  on  the  arm  about  the  insertion  of  the 
deltoid  and  make  two  or  three  circular  turns  about  the  arm.  Next 
carry  the  roller  across  the  shoulder,   approaching  the  sound  axilla 


Fig.  38. — Spica  for  shoulder. 
{Heath.) 


Fig.  39. — Bandage  for 
head.     {Stewart.) 


Fig.  40. — Barton's 

bandage.   {Gould's 

Ill.ust.  Diet.) 


from  behind;  across  under  the  axilla  and  over  the  breast  to  the  injured 
shoulder  and  around  the  arm  again  (Fig.  38). 

Bandage  for  the  Neck. — The  shoulder  and  head  must  be  included  in 
the  bandage  for  the  neck  if  it  is  to  be  effective.  Begin  on  the  shoulder 
and  carry  the  roller  through  the  axilla  and  around  the  neck  once  or 
twice.  Take  the  turn  next  about  the  neck  and  beneath  the  jaw,  be- 
hind the  ear  on  the  sound  side,  over  the  top  of  the  head,  down  in  front 
of  the  ear  on  the  affected  side.  Next  carry  the  roller  horizontally 
around  the  neck  and  then  beneath  the  jaw  once  more;  again  vertically 
around  the  head,  but  this  time  it  passes  in  front  of  the  ear  on  the  sound 
side  and  behind  the  ear  on  the  affected  side.     Carry  the  roller  now  a 


BANDAG1     POH    nil     III  \i>. 


Fig.  41. — Capitcllum.     (Heath.) 


44 


DRESSINGS,    BANDAGES,    SPLINTS. 


third  time  beneath  the  jaw  and,  finally,  from  the  occiput  around  the 
forehead  to  fix  the  other  turns. 

Bandage  for  the  Head. — A  dressing  may  be  secured  in  many  instances 
by  simple  turns  about  the  forehead  and  occiput;  but  the  bandage 
may  be  made  to  hold  firmer  if,  as  it  approaches  a  certain  point,  it  is 
raised  in  one  turn  and  lowered  in  the  next.  It  has  the  appearance  of  a 
spiral  reverse  (Fig.  39). 

Barton's  bandage  may  be  used  (Fig.  40).  Begin  at  the  top  of  the 
head,  carry  the  roller  beneath  the  chin,  up  to  the  vertex,  across  and  to  a 


yL  '       #  - 

it        /SSrt 

Fig.  43. — Showing  manner  in  which 
eye  is  covered  and  the  ear  engaged  in 
one  slit  in  the  bandage  and  the  occiput 
in  the  other. 


Fig.  44. — Showing  sound  eye  free 
and  manner  of  tying  together  the  two 
ends  of  the  bandage  on  the  sound  side. 


point  below  the  occiput.  From  this  point,  carry  it  forward  to  the  chin 
and  on  to  the  occiput.  Bring  it  up  to  the  top  of  the  head  and  again 
beneath  the  chin  and  proceed  as  in  the  beginning. 

Figs.  41  and  42  represent  one  method  of  applying  the  recurrent 
or  capitellum  to  the  head. 

Morley  describes  a  useful  and  practical  bandage  for  the  eye 
(J.  A.  M.  A.,  Mch.  27,  1909).  Take  a  piece  of  muslin,  or  gauze, 
long  enough  to  go  about  the  head  and  wide  enough  to  cover  the 
orbital  region.  At  its  center  cut  a  round  hole  for  the  ear  of  the 
affected  side  and  further  back  an  oblong  slit  for  the  occiput.  Trim 
the  bandage  so  as  to  uncover  the  sound  eye.  Split  the  two  ends  and 
tie  these  tails  tight  enough  to  prevent  slipping. 


WOOD]  \    SP]  i 


The  crossed  bandage  for  both  eyes  is  a  figure  of  eight  with 
turns  about  the  head  I  Fig.  45). 

Bandage  for  a  Stump.  Begin  with  circular  spiral  turn-  somi 
tance  up  the  limb.  Carry  the  bandage  back  and  forth  over  thi 
of  the  stump,  and  finish  by  more  i  ircular  turns. 

SPLINTS. 


To  immobilize,  to  prevent  muscular  contraction,  <>r  to  secure  fun< 
tional  rest,  splints  play  a  large  part  in  surgical  practice.     Theemer 
gency  surgeon  must  be  familiar  with  the  principles  regulating  their 
employment  and  with  the  practical  details  of  their  use.      \  splii  I 
have  rigidity;  it  should  be  light.     A  number  of  materials  offer  these 
properties  in  varying  degrees,  though  none  are  ideal  perhaps,  or  univer 
sally  applicable — wood,  metal,  leather,  wire,  card- 
board   felt,    plaster  of    Paris,   silicate'   of   potash — 
each   has   its  special  field  of   usefulness.      More 
especially    employed    in    emergency    practice    are 
wood,  metal,  and  plaster. 

Wooden  Splints. — Wood  is  the  material  usually 
most   available   when   temporary  splints   must   be 
improvised.     Often   these  splints  may  be  used  for 
permanent  fixation,  though  not  so  much  so  per- 
haps as  formerly.     From  soft  wood — a  thin  pine 
wood  -the  appropriate   form    may    be    readily    whittled;   and,   when 
applied,    well    wrapped   so   as    to   conform    to   the    pari-,    furnishes 
fixation    at    once    light    and    rigid.       The  splint    must   be  wider  I 
the  limb  and  long  as  the  part  to  be  immobilized,   but   not   so  loin; 
as  to   produce  discomfort.      Tin-    sound    limb    may    be    used 
pattern    in  modeling  the  splint.      Such  splints  have  the  disadvantage 
that    they   are   hard    to   keep    in    plan-.      A   number  of  thin   wi 
strips  may  be  glued  to  felt,  or  held  together  by  adhesive  plasti 
form  effective  fixation  in  certain  fractures  of  the  humerus  and  thigh, 
On  this  principle  the  Dutch  cane  splints  are  constructed  for 
emergencies  of  warfare.      Gooch's  splint   is  made  from  a  pme  I 
2  feet  long  and  6  or  8  inches  wide  and  1     1  inch  thi.  k.  p 


46  DRESSINGS,    BANDAGES,    SPLINTS. 

and  then  split  in  strips  3/4  inch  wide.  Before  the  ordinary  wooden 
splint  is  applied,  it  should  be  padded  with  absorbent  cotton  2  to  4  inches 
thick  and  wrapped  with  a  gauze  roller.  The  cotton  should  be  distrib- 
uted to  correspond  to  the  irregularities  of  the  limb.  The  splint  is 
molded  to  the  limb,  and  held  in  place  with  adhesive  strips  while  the 
roller  bandage  is  applied. 

Metal  splints  as  ordinarily  employed  are  scarcely  available  in 
emergency  practice.  These  materials  cannot,  as  a  rule,  be  readily 
worked  into  shape;  but,  on  the  other  hand,  if  ready-made,  are  likely 
not  to  fit.  However,  in  case  of  necessity,  a  splint  could  be  cut  from  tin 
or  from  wire  gauze.  Wire  gauze,  indeed,  forms  part  of  the  outfit 
of  the  military  emergency  bag.  It  can  be  patterned,  molded  and 
bandaged  to  the  part;  the  cut  edges  should  be  turned  over  or  covered 
with  cloth. 

Plaster. — Plaster  of  Paris,  on  the  whole,  is  the  material  best  adapted 
to  the  exigencies  of  emergency  practice.  It  is  not  too  bulky,  cheap, 
easily  obtained,  and  readily  prepared;  once  applied,  it  is  not  unduly 
heavy  and  furnishes  a  firm  support.  It  has  the  special  advantage  that 
it  can  be  molded  to  the  part;  the  disadvantage,  that  it  may  be  difficult 
to  remove  when  applied  as  a  roller  bandage.  Plaster  is  spoiled  by 
exposure.  One  should  buy  a  good  quality  and  keep  it  dry.  Old 
plaster  should  be  baked  before  using.  Plaster  may  be  applied  on  a 
roller  bandage  or  on  strips  to  make  a  molded  splint.  The  splint 
form  is  better  when  the  parts  must  be  frequently  inspected  or  when 
much  swelling  is  anticipated.  The  plaster  roller  may  be  prepared  from 
the  ordinary  gauze  roller  or  from  crinoline.  The  latter  is  perhaps  the 
best.  The  rollers  should  be  about  4  yards  in  length;  2,  3  and  5  1/2 
inches  in  width.  To  prepare  the  plaster  bandage,  pour  the  plaster  on 
a  table  or  in  a  wide  shallow  basin.  Start  the  loose  end  of  the  roller 
through  the  plaster,  rubbing  it  in  thoroughly,  and  as  fast  as  it  is  im- 
pregnated have  the  assistant  re-roll  it  (Fig.  46).  These  bandages  will 
keep  indefinitely  in  an  air-tight  container.  Prepared  in  this  way  they 
are  much  more  satisfactory  than  if  bought  ready-made — and  certainly 
much  less  expensive. 

Method  of  Applying. — When  the  limb  is  ready,  washed,  and  covered 
with  glazed  cotton  or  stockinet,  the  plaster  roller  is  set  in  a  pan  of  warm 


I'l    \^l  I    K     SP]   l\  I-. 


water  deep  enough  t<>  cover  it.     When  the  bubble 

ready  to  apply.     Seizing  it  at  each  end,  wring  it  gently.     B 

making  a  few  oblique  turns  at  tir-t  to  se<  ure  the  dressing  <t  « otton 

then  cover  the  limb  by  systemati<  i  ircular  turns,  pr 

low  upward,  each  turn  overlapping  the  preceding  one.     Th< 

must  not  be  used.     A  little  loose  plaster  may  be  spread  on  and  n 

ened  to  give  a  smooth  and  even  finish.     The  limb  must  be  supp 

and  the  extension  maintained  until  the  plaster  has  hardened.       \  little 

salt  added  to  the  water  hastens  the  process.     If  there  is  dang 


IV  I  I  I  ililli 

*fth  1 ' '  ill  Hi 

^  iiilliiMiiiliH 


FlG.  46.  —  Method  of  rolling  plasti  ■ 

swelling,  or  if  the  limb  cannot  be  frequently  inspected,  it  is  better  to 
split  the  case  before  leaving  the  patient.     Sometime-  it  is  quite 
to  split  a  plaster  cast  after  it  is  thoroughly  hardened.     The  labor  may 
be  .^reatlylessened  by  the  use  of  simple  syrup,  .1  groove  being  fii 
with  plaster  knife  or  saw;  if  the  groove  is  kept  filled  with  syrup  while 
the  cutting  is  in  progress,  one  will  get  through  the  plaster  rapidly. 

Plaster  splints  are  made  by  cutting  several  thicknesses  of  crinoline, 
appropriate  to  the  shape  of  the  limb.     It  is  saturated  with  pi 
each  layer  separately,  dipped  in  warm  water  until  well  soaked,  then 
applied  and  molded  to  the  limb.     Fix  it  with  circular  turn-  of  a  mus 
Lin  bandage.     The  second  splint,  if  needed,  is  then  applied  and 
by  a  second  series  of  circular  turns.     The  splints  may  be  I 
plaster  roller  if  desired.     A  still  better  way  is  to  fold  the  <  rinoline  i 
the  desired  number  of  layers  and  cut  them  all  at  once  from  the  | 
determined.      Warm  water  and  a  basin  are  next  provided  ai 

slowly  sifted  into  the  water,  until  it  ceases  to  bubble;  when  it 


4s  DRESSINGS,    BANDAGES,    SPLINTS. 

until  it  has  the  consistency  of  cream.  The  cloth  is  then  dipped  in  an 
saturated.  When  well  soaked,  the  excess  of  plaster  is  pressed  out  ant 
the  splint  is  ready  to  apply. 

The  Bavarian  plaster  splint  is  particularly  useful  in  immobilizing 
the  leg.  Cut  two  pieces  of  flannel  long  enough  to  extend  from  the  up- 
per end  of  the  thigh  under  the  heel  to  the  ball  of  the  toes,  a  few  inches 
wider  than  the  greatest  girth  of  the  limb.  Stitch  these  pieces  together 
along  the  middle  line  for  the  length  of  the  leg.  Put  the  splint  thus 
formed  under  the  limb,  with  the  seam  exactly  in  the  middle;  bring 
the  inner  half  around,  fitting  it  to  the  leg,  the  dorsum  and  sole  of  the 
foot,  like  a  stocking.  Smear  this  stocking  with  liquid  plaster  and 
before  it  sets,  turn  the  outer  half  over  the  plaster  and  mold  it  and  adjust 
the  end  pieces  to  the  sole.  The  splint  can  be  easily  removed,  as  the 
seam  along  the  back  acts  as  a  perfect  hinge. 


CHAPTER  VII. 
SHOCK. 

Shock  is  a  constitutional  state  characterized  by  lowered  blood  pres- 
sure, due  to  vaso-motor  paralysis. 

Peripheral  impulses  traveling  along  the  afferent  nerves  reach  the 
spinal  cord  and  overwhelm  those  centers  which  regulate  the  blood 
pressure. 

In  practice,  the  term  "shock"  includes  the  complex  of  symptoms 
arising  from  the  vaso-motor  paralysis,  hemorrhage,  mechanical  interfer- 
ences with  circulation  and  respiration,  and  beginning  infection. 

It  may  not  be  possible  to  analyze  the  symptoms,  determining  the  part 
played  by  each  of  these  various  conditions,  nor  is  it  necessary  to  do  so. 

Nevertheless,  the  proper  understanding  of  shock  as  a  separate  entity 
is  essential  in  emergency  surgery  next  to  skill  in  hemostasis. 

Lucy  Waite  (Medical  Record,  Sept.  8,  1906),  after  reviewing  the 
subject  from  every  standpoint,  concludes  that,  according  to  our  present 
light,  we  must  consider  it  primarily  a  disturbance  of  the  great  sympa- 
thetic nervous  system;  secondarily,  the  vascular  system,  resulting  in 
vaso-motor  paresis  and  dilatation  of  the  right  side  of  the  heart  and 
the  large  vessels;  in  natural  sequence  derangement  of  the  solar  plexus 
and  the  automatic  visceral  ganglia  follows;  finally  there  is  suppres- 
sion of  visceral  activity — of  rhythm,  absorption,  and  secretion. 

The  symptoms  of  shock  vary  in  degree  with  its  severity  and  are 
chiefly  incident  to  the  lowered  blood  pressure:  thirst,  pallor,  subnor- 
mal temperature,  shallow  breathing,  frequent  sighing  or  yawning, 
rapid  pulse,  relaxed  sphincters,  faintness,  nausea  or  vomiting,  and 
unconsciousness. 

These  may  appear  in  their  slightest  manifestations,  or  in  such  forms 
as  usher  in  death.  As  Waite  says,  syncope  causing  always  a  cerebral 
anemia  is  practically  identical  with  the  last  manifestations  of  over- 
whelming shock. 

4  49 


50  SHOCK. 

Whether  shock  will  be  mild,  severe,  or  fatal  depends  upon  the  state 
of  the  individual,  the  character  and  continuance  of  trauma,  the  means 
of  injury,  and  the  tissues  wounded.  Age,  sex,  general  health,  and 
mental  state  are  factors  to  be  taken  into  consideration. 

Crushing  injuries  with  mangled  nerves  sending  their  constant  sig- 
nals to  the  exhausted  vaso-motor  centers  furnish  conditions  favorable 
to  fatal  shock.  Railroad  accidents  as  a  means  of  injury  are  typical 
of  such  as  produce  the  severest  symptoms  of  shock,  for  fright  and 
violent  emotions  even  without  injury  may  be  followed  by  vaso-motor 
paralysis. 

Certain  tissues  resent  insult  more  than  others.  Those  which  line 
the  body  cavities  are  most  sensitive  with  respect  to  injury;  the  perito- 
neum, the  pleura,  the  dura,  and  the  synovial  membranes  of  the  large 
joints.     This  is  true  whether  the  trauma  be  accidental  or  operative. 

The  diagnosis  of  shock  as  distinct  from  hemorrhage  and  collapse  can- 
not always  be  made  with  certainty.  As  Waite  says,  the  diagnosis  of 
shock  is  simply  the  recognition  of  the  clinical  phenomena,  for  we  have 
no  chemical  or  pathological  findings  to  aid  us. 

In  many  instances  it  may  be  differentiated  from  collapse  by  the 
history  of  the  case. 

In  collapse  the  heart  action  is  slow  and  feeble,  whereas  in  shock  it 
is  rapid  and  feeble. 

In  hemorrhage  the  symptoms  may  be  rapidly  progressive,  but  in 
uncomplicated  shock  the  symptoms  are  stationary  or  improve.  Ob- 
serve, therefore,  the  action  of  the  pulse  and  the  movement  of  the  tem- 
perature. In  hemorrhage  the  temperature  falls  and  the  pulse  rate  in- 
creases. In  shock  the  pulse  becomes  gradually  slower;  the  tempera- 
ture gradually  rises. 

The  prognosis  in  the  severe  cases  will  be  for  a  little  time  decidedly 
uncertain.  The  sufferer  from  traumatic  shock  may  give  the  doctor  an 
erroneous  notion  of  the  gravity  of  the  case,  unless  the  condition  of  the 
pulse  is  carefully  noted;  for  he  may  complain  of  no  pain,  is  cheerful 
in  the  face  of  his  calamity,  discusses  the  need  of  operative  measures 
quite  coolly  and  directs  the  management  of  his  case  generally.  He 
seems  quite  rational,  and  yet  it  often  happens  that  after  recovery  he  has 
no  recollection  of  what  he  said  or  did  or  felt.     It  is  probable,  in  the 


!'l  VGNOSIS    "I     SHO(  K. 


presence  of  grave  injury  that,  if  the  pulse  is  thread)  and    till  I 
the  patient  dot's  m>t  know  what  he  is  talking  about,  ho  vever  tut  id  Ins 
expression  may  appear.     A  little  later  he  may  be  in  active  delirium 
\iv  increase,  not  too  long  delayed,  in  the  I  >!•  ><  >•  I  pressure  and  if 
tendant  improvement,  is  a  cause  for  hope.     It  may  take  m 
before  the  reaction  is  (  omplete. 

Any  aggravation  of  the  symptoms  alter  reaction  is  once  undet 
indicates  a   return   of  the  shock,   hid  points   to  hemorrha 

It  is  true  that,  as  a  rule,  when  on,  e  improvement  begins  the  outlook 
is  favorable,  but  the  prognosis  must  alu  ays  be  guarded  in  tin- 1  ase  of  the 

elderly. 

An  old  flagman  was  brought  to  the  City  Hospital  with  both  limbs 
crushed  off,  having  fallen  under  a  passing  engine.  He  a-  in  full  shot  k 
and  had  lost  some  blood  from  a  scalp  wound.  He  was  almost  pul 
and  vet  his  mind  seemed  clear.  His  condition  precluded  operation. 
His  wounds  were  trimmed  of  mangled  tissue  and  t  arcfullv  «  leansed  and 
wrapped  in  moist  antiseptic  compress  until  su<  h  time  as  formal  ampu- 
tation might  be  undertaken.  Under  the  treatment  for  shock  he 
gradually  improved.  His  circulation  and  respiration  grew  stronger, 
but  not  sufficiently  so  to  favor  operation.  At  the  end  of  twenty  four 
hours  he  began  all  at  once  to  grow  weaker,  fell  into  a  stupor,  and  in  a 
few  hours  died.  If  the  amputation  had  been  undertaken,  he  would 
have  died  on  the  table,  and  thus  another  fatality  would  have  Keen 
charged  to  active  intervention. 

The  treatment  of  shock  has  been  the  subject  of  much  <li-<  u--i«>n  in 
recent  years.     The  most  diverse  opinions  exist  and  tin-  most  diverse 
methods  have  been  proposed,  but  we  have  learned  from  the  experience 
of  ("rile  and  others  that  it  i-  as  important  to  know   what  n 
what  to  do. 

The  whole  list  of  cardiac  and  spinal  stimulants  so  commonly  ii 
jected  hastily,  indiscriminately  and  collectively,  are  shown  to  be  not 
only  useless,  but  distinctly  harmful.      The  patient  doubtles 
covers  not  on  account  of,  but  in  spite  of.  such  treatment. 

In  ordinary  cases,  these  dire<  tions  are  suffii  ient  to  be  borne  in  mi 
disturb  the  patient  as  little  as  possible;  lower  the  head;  keepthi 

warm;  attempt  no  operative  measures  until  the  symptom-  .ire  imp: 


52  SHOCK. 

unless  it  be  to  check  hemorrhage,  or  to  amputate  in  certain  crush- 
ing injuries. 

Adrenalin  chloride  is  the  most  generally  useful  remedy  to  raise 
blood  pressure  in  shock  pure  and  simple,  and  given  hypodermically 
or  intravenously,  it  very  seldom  completely  fails. 

Crile  was  enabled  by  means  of  intravenous  infusion  of  adrenalin  and 
salt  solution,  combined  with  artificial  respiration  and  thoracic  pres- 
sure, to  arouse  a  human  heart  after  it  had  ceased  to  beat  for  nine  min- 
utes, and  its  action  was  thus  sustained  for  one-half  hour. 

It  must  be  given  in  small  doses,  frequently  repeated.  The  effects 
are  powerful,  but  fleeting. 

Hypodermically,  give  5  to  15  minims  of  the  1-1000  adrenalin  solu- 
tion and  repeat  every  20  or  30  minutes. 

Intravenous  infusion  is  even  more  satisfactory  and  certain.  Give 
continuous  infusion  of  adrenalin  salt  solution  until  there  are  signs  of 
reaction.  One  teaspoonful  of  1-1000  adrenalin  added  to  one  quart 
of  normal  salt  solution  is  of  sufficient  strength. 

Normal  salt  solution  alone  is  effective  within  certain  limits,  but  finds 
its  greatest  field  of  usefulness  in  shock  coexistent  with  hemorrhage. 
In  shock  uncomplicated  by  extensive  loss  of  blood,  the  saline  solution 
must  be  used  sparingly,  perhaps  better  by  enema  or  hypodermoclysis; 
used  in  large  quantities  intravenously,  it  may  eventually  defeat  the  end 
for  which  it  is  employed  by  acting  as  a  mechanical  obstruction  to  respira- 
tion. For  it  must  be  remembered  that  under  such  circumstances  it 
finds  its  way  into  the  thoracic  and  abdominal  tissues  and  interferes 
with  the  movements  of  the  diaphragm  and  ribs  by  its  mere  presence. 
According  to  Crile,  320  c.c.  per  kilo  of  body  weight  led  to  such  accumu- 
lation of  fluid  in  the  splanchnic  area  as  to  embarrass  respiration. 

Do  not  give,  then,  more  than  two  or  three  pints  of  normal  salt  solu- 
tion injected  slowly,  in  uncomplicated  shock.  (For  technic  of  in- 
travenous infusion,  see  page  56.) 

Crile's  pneumatic  suit  seems  to  be  entirely  trustworthy  as  a  means 
of  raising  blood  pressure;  but,  of  course,  cannot  be  used  in  the  shock 
occurring  in  emergency  practice. 

The  prevention  of  shock  is  always  something  to  be  considered  in 
operative  work.     Morphia,  1/4  grain  hypodermically,  before  the  anes- 


PRi  \  i  \i  [ON    "i    S K.  53 

thesia,  is  a  real  aid.  "  Blocking"  the  nerves  by<  o<  aine  injei  tions  above 
the  site  of  operation  is  Likewise  advantageous  and  is  recommended  by 
Cushing  and  Crile.  The  nerve  may  be  exposed  in  its  course  under 
local  anesthesia  and  in  turn  injected. 

In  abdominal  work  the  viscera  must  be  handled  with  care;  for,  as 
Byron  Robinson  has  shown,  shock  from  this  source  is  directly  propor- 
tionate to  the  amount  of  manipulation  or  traction  upon  the  viscera. 


CHAPTER  VIII. 
HEMORRHAGE. 

DEFINITIONS. 

i.  Arterial  hemorrhage  is  due  to  wounds  of  arteries  and  is  character- 
ized by  spurting  and  the  bright  red  color. 

2.  Venous  hemorrhage  is  due  to  wounds  of  the  veins  and  is  character- 
ized by  dark  color  and  steady  flow. 

3.  Capillary  hemorrhage  is  characterized  by  persistent  oozing  and 
spontaneous  arrest. 

4.  Parenchymatous  hemorrhage  is  due  to  wounds  of  those  organs 
and  tissues  in  which  the  small  arteries  terminate  directly  in  veins;  no 
capillaries  intervening,  as  in  the  erectile  tissues. 

5.  Primary  hemorrhage  occurs  immediately  after  the  injury. 

6.  Intermediate  or  reactionary  hemorrhage  occurs  within  twenty- 
four  hours  and  is  due  to  the  release  of  clots  or  the  slipping  of  the 
ligature. 

7.  Secondary  hemorrhage  occurs  after  twenty-four  hours,  before  the 
cicatrization  of  the  wound,  and  is  usually  due  to  sloughing  or  suppu- 
ration or  the  too  rapid  absorption  of  the  catgut  ligature. 

8.  Internal  or  concealed  hemorrhage  occurs  when  the  blood  is 
emptied  into  one  of  the  large  cavities;  abdomen,  thorax  or  cranium. 

CONSTITUTIONAL    EFFECTS    OF    HEMORRHAGE. 

The  constitutional  effects  of  hemorrhage  vary  with  the  amount  and 
the  rapidity  of  the  loss  of  blood.  Thus  a  comparatively  small  amount 
of  blood  poured  out  rapidly  will  produce  more  marked  symptoms  than 
a  much  larger  amount  drained  away  slowly. 

The  constant  accompaniments  of  severe  hemorrhage  are  pallor,  dizzi- 
ness and  faintness,  rapid  and  weak  pulse,  subnormal  temperature, 

54 


M  ^GNOSIS   "l    hi  IfORSHAG]  ,  55 

rapid  and  irregular  breathing,  frequent  yawning  or  sighing,  nausea, 
and  vomiting. 

Fatal  hemorrhage,  or  one  likely  to  be  so,  is  indicated  by  livid  lips 
blue  anger  nails,  dilated  nostrils,  pallid  mucous  membranes,  dyspnea, 

ringing  in  the  ears,  syncope,  collapse  and  unconsciousness. 

Subsequent  to  the  arrest  of  a  dangerous  hemorrhage,  occur  rapid  and 
irregular  pulse,  rise  of  temperature,  asthenia,  a  disturbed  mental  con- 
dition, usually  muttering  delirium.  This  is  hemorrhagic  fever.  As 
the  general  condition  improves,  the  mind  gradually  clears  up.  The 
lowered  vitality  following  the  hemorrhage  favors  the  development  of 
various  inflammatory  processes,  and  one  must  carefully  watch  for  the 
onset  of  these. 

The  diagnosis  of  hemorrhage  is  not  difficult  except  in  the  case  of 
internal  hemorrhage,  or  when  shock  is  present. 

In  the  case  of  bleeding  into  the  cranial  cavity,  various  forms  of 
paralysis  and  nervous  disturbances,  together  with  the  general  symp- 
toms, will  form  the  basis  of  the  diagnosis. 

In  the  case  of  bleeding  into  the  thorax  and  abdomen,  the  symptoms, 
the  physical  signs,  and  the  history  of  the  case  will  point  to  the  condition. 
(See  Injuries  to  Thorax  and  Abdomen.) 

When  shock  is  also  present  it  may  be  almost  impossible  to  tell  how 
much  of  the  symptoms  are  due  to  the  one  or  the  other,  for  the  symptoms 
of  shock  and  hemorrhage  are  practically  identical. 

It  is  useful  to  remember  that  the  symptoms  produced  by  shock  are 
usually  immediate  and  tend  to  improve,  except  in  the  fatal  cases. 
On  the  other  hand,  the  symptoms  of  unchecked  hemorrhage  tend  to 
grow  worse. 

TREATMENT   OF    HEMORRHAGE. 

The  First  Indication  is  the  Arrest  of  Hemorrhage.  Constitutional 
measures  are  then  applied  with  a  view  to  supporting  the  heart's  action. 
In  moderately  severe  cases  give  1  2  ounce  of  whiskey  or  a  hypodermic 
of  strychnia  {i,6o  t<>  i,  20  gr.),  or  of  adrenalin  chloride,  and  repeat 
ever}'  hour  until  the  symptoms  have  improved.  Apply  warm  blankets, 
hot  water  bottles,  or  hot  irons  well  wrapped.  1  >o  not  burn  the  patient. 
Keep  him  quiet,  with  head  Lowered.     Attend  to  the  ventilation.     As 


56  HEMORRHAGE. 

soon  as  possible  give  warm  drinks  and  a  nutritious  but  easily  digested 
diet.  Do  not  overstimulate,  as  the  reaction  in  that  case  will  be  un- 
duly severe. 

In  the  dangerous  cases  of  hemorrhage,  in  addition  to  these  measures, 
do  not  fail  to  employ  normal  salt  solution  either  by  enema,  subcutaneous 
injection,  or  intravenous  infusion. 

In  the  gravest  cases,  enemas  will  be  of  no  avail,  for  absorption  has 
practically  ceased. 

Hypodermoclysis  will  be  a  little  better.     For  this  purpose  employ: 

1$ — Sodii  chloridi.,  5     i. 

Sodii  bicarb.,  gr.  xv. 

Aq.  destill.,  o     xvi. 

The  necessary  apparatus:  a  carefully  disinfected  fountain  syringe  or  a 
funnel  with  rubber  tubing,  a  large  needle  (an  aspirating  needle).  One- 
half  pint  or  more  of  the  solution  is  injected  by  this  means  under  the 
skin  over  the  abdomen  or  breasts. 

Intravenous  Infusion.  In  the  gravest  cases,  the  same  solution  by 
the  same  means  may  be  injected  into  the  venous  circulation.  Select  a 
vein  at  the  elbow,  employ  the  strictest  asepsis,  and  expose  the  vein  by 
incision.  Loosen  it  from  adjacent  tissues  by  careful  blunt  dissection 
and  slip  three  catgut  ligatures  under  it.  Introduce  the  needle,  or  else 
the  vein  may  be  opened  and  a  cannula  used.  The  cannula  or  needle  is 
to  be  held  in  place  by  tying  the  middle  ligature.  Slowly  inject  a  pint  or 
more  of  the  solution,  the  temperature  of  which  should  be  105  to  115. 
Withdraw  the  cannula,  remove  the  middle  ligature,  and  tie  the  two  re- 
maining. Close  the  wound  and  dress  aseptically.  Keep  the  funnel 
full  during  the  injection,  so  that  no  air  may  be  carried  into  the  vein. 

Crile  recommends  direct  transfusion  from  the  vein  of  a  well  person 
into  that  of  the  patient,  but  of  course  this  method  is  scarcely  available 
in  emergencies  of  general  practice. 

Parke-Davis  &  Company  market  a  sterile  salt  in  sterile  tubes 
which  needs  only  to  be  emptied  into  a  liter  of  sterile  water  to  form  a 
solution  for  instant  use.     The  formula  used  is  as  follows: 

Calcium  chloride,  0.25  gm. 

Potassium  chloride,  0.1      gm. 

Sodium  chloride,  9.0     gm. 


ARRI  ST   OF    III  iffORKB  \<u  .  >7 

Remember  that  intravenous  infusion  is  not  to  be  employed  until  the 
hemorrhage  is  arrested. 


Ill  MOSTASIS — ARREST    OF    HEMORR  I  IAC.I . ;    GKNKRAL    PRINCIPLES. 

Spontaneous  arrest  of  hemorrhage  is  due  to  several  factors:  contrac- 
tion and  retraction  of  the  injured  vessels,  diminishing  blood  pressure 
due  to  weakening  heart  action,  formation  of  a  clot;  these  are  the  agents 
which  nature  employs. 

Capillary  hemorrhage  tends  to  spontaneous  arrest,  likewise  the 
arterial  hemorrhage  of  lacerated  wounds. 

Hemostatic  measures  locally  applied  are  chemical,  thermal,  and 
mechanical. 

(A)  Chemical  remedies,  chiefly  styptics,  are  now  very  rarely  em- 
ployed. Such  as  are  used  are  expected  to  favor  the  formation  of  a  clot 
without  doing  violence  to  the  tissues.  In  a  persistent  capillary  hemor- 
rhage, dioxide  of  hydrogen  or  acetanilid  is  often  useful  and  harmless, 
but  the  most  useful  remedy  locally  applied  is  adrenalin  chloride. 
The  i-iooo  solution  is  commonly  used. 

(B)  Thermal  hemoslasis  is  that  induced  by  heat.  Hot  water  or  hot 
normal  salt  solution  alone  will  usually  arrest  a  moderate  bleeding. 
Use  the  solution  as  hot  as  can  be  borne  by  the  hand.  Hot  solutions  are 
especially  useful  since  they  serve  the  double  purpose  of  antisepsis  and 
hemostasis.  The  actual  cautery  may  be  necessary  in  spongy  tissue 
where  the  oozing  is  persistent  but  ill  defined.  The  iron  should  not  be 
hotter  than  a  dull  red  and  must  be  held  in  contact  for  some  moments. 
Cold  may  be  used  but  is  much  more  likely  to  lower  cellular  vitality. 

(C)  Mechanical  hemostasis  includes  (i)  direct  pressure,  (2)  com 
prcssion,  (3)  acupressure,  (4)  forcipressure,  (5)  torsion,  (6)  ligation. 

(1)  Direct  pressure  is  of  large  service  especially  in  "  first  aid"  treat- 
ment. The  finger  or  thumb  is  pressed  directly  into  the  wound,  or  on 
each  edge  of  the  wound.  If  the  pressure  is  to  be  prolonged,  the  finger 
will  tire  and  a  plug  or  tamponade  of  gauze  must  be  substituted. 
Gauze  wrung  out  of  a  sterile  solution  is  packed  into  the  wound. 

Direct  pressure  is  sufficient  in  the  slight  hemorrhage  of  operative 
wounds.    The  assistant  presses  a  gauze  compress  on  the  bleeding  sur- 


58  HEMORRHAGE. 

face,  withdraws  it  by  a  gliding  movement,  and  the  bleeding  practically 
ceases. 

In  general,  the  larger  the  vessels,  the  firmer  and  more  prolonged 
must  be  the  pressure. 

In  severe  hemorrhage,  direct  pressure,  is  of  course,  a  mere  temporary 
expedient. 

Parenchymatous  bleeding  is  checked  by  direct  pressure.  The 
wound  of  the  organ  is  lined  with  a  layer  of  gauze.  In  this  gauze 
cavity,  complete  the  tamponade.  This  compress  should  be  withdrawn 
within  twenty-four  to  forty-eight  hours.  It  may  be  painful  to  pull  out. 
Release  a  little  at  a  time,  or  soften  the  adhesions  with  peroxide. 

2.  Compression  aims  to  occlude  the  vessel  above  or  below  the  wound. 
In  the  emergency,  a  finger  is  applied  to  an  artery  at  some  con- 
venient point  along  its  course  at  some  distance  above  the  wound. 
Pressure  is  most  effective  if  the  vessel  lies  closely  over  bone.  Large 
veins  are  similarly  compressed  below  the  wound. 

In  the  case  of  wounds  of  the  extremities,  the  main  vessels,  including 
both  the  vein  and  artery  or  either  alone,  may  be  compressed  by  the 
tourniquet.  The  pressure  is  made  firmest  over  the  vessel  by  laying 
oyer  its  course  a  body  such  as  a  small  roller  bandage,  before  the  con- 
stricting band  is  applied  above  the  wound  (Figs.  51,  52). 

The  simplest  and  most  convenient  tourniquet  is  a  rubber  band  or 
tube.  After  being  tightened,  the  crossed  ends  are  caught  and  held 
in  place  by  an  artery  forceps.  It  must  always  be  remembered  that 
the  tourniquet  is  likely  to  cut  off  all  the  blood  supply  to  the  extremity 
and  if  too  long  applied  will  produce  gangrene.  Paralysis  may  follow 
from  pressure  on  the  nerves.  Wrap  the  arm  with  towel  and  apply 
the  tourniquet  over  that. 

Capillary  oozing  is  frequently  troublesome  after  the  constriction  is 
removed.     Constriction  is  objectionable  on  that  account. 

3.  Acupressure  is  now  seldom  used  and  yet,  under  certain  circum- 
stances, may  render  great  aid.  The  artery  may  be  deep  and  retracted 
or  imbedded  in  scar  tissue  or  aponeurosis  and  cannot  be  seized  by  the 
forceps.  In  such  a  case  a  needle  passed  under  the  artery  and  secured 
with  a  figure-of-eight  ligature  wound  around  its  protruding  ends  will 
press  the  artery  between  it  and  the  tissues  and  stop  the  flow  (Fig.  47). 


\i:ki  -l    .)l     III  MORRH  \«.i  . 


59 


i.  Forcipressure,  the  control  of  hemorrhage  by  seizing  the  ends  of  the 
bleeding  vessels  with  Forceps,  is  the  expedient  most  commonly  em 
ployed  in  operative  wounds.  In  the  accidental  wounds  of  Large 
trteries,  it  affords  immediate  control  of  the  hemorrhage.  For  the 
small  vessels  such  pressure  is  sufficient,  the  forceps  remaining  at- 
tached for  a  certain  length  of  time.  The  end  of  the  vessel  should  be 
seized  with  as  little  other  tissue  as  possible.  If  it  is  a  large  vessel  it  may 
he  cleared  by  a  moment's  dissection. 

5.  Torsion  is  added  to  forcipressure,  if  that  is  not  sufficient  (Fig. 
48).  Before  removing  the  forceps,  it  is  given  t\yo  or  three  turns  on 
its  long  axis.     The  inner  coats  of  the  artery  are  ruptured  and  con- 


Fig.  47. — -Acupressure.      (Moitlliu.) 


traded,  producing  the  same  conditions  favorable  to  hemostasis  as  are 
found  in  the  artery  in  Lacerated  wounds.  If  the  artery  is  a  little  larger, 
it  is  drawn  for  1  2  inch  out  of  its  sheath,  a  second  forceps  grasps  it 
higher  up  and  is  held  stationary,  while  the  lower  one  twists  the  in- 
tervening segment,  the  purpose  being  to  avoid  injury  to  the  sheath  and 
the  vasovasorum. 

In  making  torsion,  do  not  pull  at  the  same  time,  for  fear  of  tearing 
the  odier  tissues  instead  of  twisting  the  artery.  Torsion  must  not  lie 
used  where  the  tissues  are  loose  or  cellular. 

Torsion  is  of  advantage  especially  in  plastic  surgery,  for  it  leaves  no 
ligature  behind  to  interfere  with  repair;  hut  it  is  not  so  certain  as 
ligation. 

6.  Ligation  is  finally  necessary  in  bleeding  from  the  Larger  vessels. 
Employ  catgut,  chromicized  or  plain,  and  occasionally  silk. 


6o 


HEMORRHAGE. 


Lift  the  attached  forceps  so  as  to  create  a  pedicle  around  which  pass 
the  thread  and  tie  the  first  knot  (Fig.  49). 

In  tying  the  second  knot,  two  things  are  kept  in  mind;  to  tie  tight 
enough  that  the  thread  will  hold  when  the  forceps  is  removed,  and  not 
to  include  the  tip  of  the  forceps  in  the  ligature.  The  forceps  is  usually 
removed  as  soon  as  the  first  knot  is  tied,  so  that  one  may  be  assured  the 
suture  is  not  badly  placed  before  completing  the  knots.  The  first  knot 
is  secured  by  a  second  if  silk  is  used,  and  by  a  third  if  catgut  is  used. 
The  threads  are  then  cut  short,  silk  1  mm.  and  catgut  2  or  3  mm. 
Catgut  is  the  preferable  ligature  and  a  No.  2  is  amply  strong  for  an 
artery  the  size  of  the  radial. 


Fig.  48. — Torsion.     (Veau.) 


Fig.     49. — Showing     method     of 
tightening  the  ligature.      (Veau.) 


Ligation  en  masse  may  be  employed  in  parenchymatous  hemorrhage, 
capillary  oozing,  or  bleeding  from  a  deep  wound.  A  catgut  suture  is 
carried  around  the  bleeding  area  by  a  well  curved  needle,  and  all  the 
tissues  so  included  are  tied;  or,  in  the  case  of  parenchymatous  bleeding 
from  a  surface,  a  catgut  suture  may  be  carried  around  the  area  and 
subsequently  tightened  after  the  manner  of  the  purse  string. 

HEMOSTASIS    IN   SPECIAL   FORMS    OF    HEMORRHAGE. 

(a)  Capillary — pressure,  hot  water,  ice,  adrenalin,  peroxide,  acetani- 
lid,  alum,  ligation  en  masse. 

(b)  Venous — pressure,  compression,  forcipressure,  ligation,  removal 
of  all  obstruction  to  venous  flow  above  the  wound. 

(c)  Arterial — pressure,  compression,  forcipressure,  torsion,  ligation. 


BEMOSTASIS   IN   SPECIAL    FORMS   OF    HEMORRHAGE.  6l 

(d)  Parenchymatous    pressure  (tamponade),  heat,  ligation  en  masse. 

(e)  Intermediate  hemorrhage  reopen  the  wound,  turn  out  the  clots 
and  treat  hemorrhage  as  if  it  were  a  primary  one. 

(f)  Secondary  hemorrhage  reopen  the  wound,  turn  out  riots,  and 
apply  compresses.  If  possible  catch  the  ends  of  the  bleeding  vessels. 
If  the  hemorrhage  is  alarming  and  it  is  impossible  to  control  it  by  com- 
presses or  forcipressure,  apply  the  tourniquet,  in  the  case  of  an  ex- 
tremity, and  ligate  the  artery  in  its  continuity  above  the  wound.  If 
this  fails  and  the  artery  cannot  be  tied  higher  up,  amputate. 


Fig.  so. 

(g)  Operative  hemorrhage — In  spite  of  artery  forceps,  the  bleeding 
remains  to  the  unexperienced  one  of  the  bugbears  of  operative  work. 
In  many  operations  it  is  the  chief  drawback  to  rapid  work;  more  time 
is  lost  in  catching  and  tying  bleeding  points  than  in  doing  the  actual 
operation.  Oftentimes  the  field  is  masked  by  a  general  oozing,  and  the 
procedure  must  halt  until  the  wound  can  be  packed  with  hot  com- 
presses, which  will  usually  be  all  that  is  necessary.  Gentle  and 
momentary  pressure  with  a  gauze  compress  is  usually  all  that  is 
necessary  in  capillary  bleeding. 

In  operations  in  the  various  cavities,  as  the  nose,  mouth,  rectum,  in 
the  mastoid  operation,  etc.,  the  hemorrhage,  even  if  not  disconcerting, 
is  often  very  troublesome  and  some  special  measures  are  required. 
I'nder  the  circumstances,  Parke  Davis'  adrenalin  gauze,  which  is  cut 
in  narrow  strips,  may  be  picked  in  the  cavity  for  a  moment  and  on  its 
removal  the  operation  may  proceed  (Fig.  50). 


"62  HEMORRHAGE. 

FIRST  AID  IN  DANGEROUS  HEMORRHAGE.* 

It  is  rare  that  the  regulated  measures  for  hemostasis  can  be  applied 
first  hand  in  a  dangerous  hemorrhage.  There  are  certain  temporary 
and  makeshift  but  extremely  useful  procedures  which  the  surgeon 
should  keep  in  mind,  if  for  no  other  reason  than  that  he  may  give  pre- 
cise and  definite  instruction  to  the  layman  who  may  have  to  play  the 
part  of  surgeon  for  the  time  being. 

Intelligent  first  aid  is  the  chief  factor  in  saving  life  in  most  cases  of 
dangerous  hemorrhage  both  in  military  and  civil  practice.  Whoever 
has  to  meet  these  emergencies  must  keep  cool.  He  must  remember 
how  to  apply  three  principles  of  treatment,  position,  direct  pressure, 
compression. 

i.  Position. — In  case  the  upper  extremity  is  wounded:  hold  the  arm 
above  the  head.  If  it  is  the  lower  extremity:  put  the  patient  on  his 
back  and  elevate  the  limb.  If  it  is  the  face  or  scalp:  place  the  patient 
in  a  sitting  position. 

2.  Direct  Pressure. — The  wound  is  small,  the  bleeding  is  dangerous: 
plug  the  wound  directly  with  the  thumb  or  finger,  or  press  firmly  on 
each  edge  of  the  wound;  or,  in  any  case  and  better  still,  if  supplied  with 
a  first  aid  packet,  stuff  the  wound  tightly  with  gauze  and  bandage 
firmly.  It  should  be  emphasized  that  a  finger  must  never  be  thrust 
into  a  wound  except  in  cases  of  greatest  urgency  and  where  other  means 
less  likely  to  cause  sepsis  are  not  at  hand. 

3.  Compression. — The  bleeding  vessel  is  recognized  and  its  course 
is  familiar:  compress  it  with  the  fingers  at  some  convenient  point  or, 
in  the  case  of  the  extremities,  by  constricting  the  limb. 

In  lieu  of  the  tourniquet,  knot  a  handkerchief,  apply  the  knot  over 
the  artery  and  tie  the  handkerchief  tightly  around  the  limb.  If  it  is 
not  tight  enough,  a  stick  may  be  slipped  under  the  handkerchief  and 
given  a  few  turns,  end  for  end.  A  suspender,  a  rope,  or  a  wire  may, 
if  necessary,  be  similarly  employed.  It  must  be  remembered  that, 
on  the  whole,  circular  constriction  is  not  without  its  dangers,  and  it  must 
not  be  recommended  without  reserve  to  the  layman. 

*  See  also  "First  Aid  on  Battlefield,"  page  148. 


COMPRESSION    OF    PRINCIPAL  ARTERIES.  63 

The  principal  arteries  near  the  surfai  e  have  ea<  h  <  ertain  points  «  here 
compression  is  most  effective. 
The  temporal  and  occipital  furnish  most  of  the  dangerous  bleeding 

in  st  alp  wounds. 

The  temporal  may  be  compressed  just  in  front  of  the  upper  part  of 
the  ear. 

The  occipital  may  be  compressed  in  its  course  from  the  tip  of  the 

mastoid  upward  toward  the  occipital  protuberance. 

The  entire  blood  supply  of  the  scalp  may  be  shut  off  temporarily  by 
a  bandage  encircling  the  head,  passing  from  the  forehead,  above  the 
ear,  to  the  base  of  the  skull  and  thence  upward,  just  above  the  other 
ear,  to  the  forehead  again. 

The  facial  is  compressible  as  it  crosses  the  body  of  the  jaw  just  in 
front  of  the  masseter  muscle.  • 

The  coronary  arteries,  supplying  the  lips,  are  compressed  by  seizing 
the  lip  between  the  forefinger  and  thumb. 

The  carol  ids  are  controlled  by  compression  of  the  common  carotid 
over  the  transverse  process  of  the  sixth  cervical  vertebra. 

Wounds  of  the  vessels  of  the  neck,  however,  are  of  such  extreme 
danger,  including,  as  a  rule,  both  arteries  and  veins,  that  bleeding 
should  be  controlled  by  direct  pressure  in  the  wound.  Nothing  can 
be  so  well  trusted  here  as  the  finger. 

The  subclavian  is  compressible  against  the  first  rib  behind  the  middle 
of  the  clavicle.  The  shoulder  is  slightly  raised  to  relax  the  cervical 
fascia  and  the  finger  or  a  padded  stick  pushed  directly  down  upon  the 
artery  behind  the  clavicle.  The  circulation  of  the  entire  upper  ex- 
tremity is  thus  controlled. 

The  brachial  is  compressible  against  the  middle  of  the  humerus  or 
the  tourniquet  may  be  applied  over  any  part  of  the  artery  (Fig.  51). 

The  radial  and  ulnar  are  not  compressible  except  just  above  the 
wrist;  and.  therefore,  bleeding  from  them  must  be  controlled  by  dim  1 
pressure  in  the  wound,  or  by  the  tourniquet,  or  by  compression  of  the 
brachial. 

The  palmar  arches  are  not  directly  compressible,  but  hemorrhage 
from  the  palm  is  controlled  by  grasping  firmly  a  round  body  as  a 
billiard  ball,  an  apple,  a  stone  wrapped  with  gauze,  and  bandaging  the 


04  HEMORRHAGE. 

hand  in  this  position.  If  this  is  not  practical,  the  tourniquet  may  be 
applied  to  the  forearm,  or  the  brachial  compressed. 

The  digital  arteries  are  always  easily  controlled  by  constriction  of  the 
finger  above  the  wound. 

The  femoral  artery  is  compressible  in  the  middle  of  the  groin  against 
the  ramus  of  the  pubes,  but  great  pressure  is  required  here  to  control 
its  flow  (Fig.  52).     It  may  likewise  be  compressed  lower  down  against 


Fig.   51. — Compression  of  brachial. 
(Moullin.) 


Fig.    52. — Compression   of  femoral. 
{Moullin.) 


the  shaft  of  the  femur.  The  tourniquet  is,  in  this  instance,  the  safer 
temporary  hemostatic,  a  compress  of  some  sort  intervening  between  it 
and  the  artery. 

The  popliteal  is  not  compressible.  Bleeding  must  be  controlled  by 
direct  pressure  or  by  compression  of  the  femoral. 

The  tibials  likewise.  They  may  also  be  controlled  by  flexing  the 
knee  forcibly  upon  a  pad,  holding  the  pad  in  place  by  a  cross  piece 


TREATMENT    OF    1  IMS  1  AX  IS. 


65 


pressing  forcibly  againsl  the  popliteal  space,  and  in  turn  held  in  place 
by  a  bandage  around  the  flexed  leg  (sec  Fig.  103,  p.  152). 

The  dorsal  and  plantar  arteries  can  best  be  controlled  by  direct 
pressure  or  by  compressing  the  tibials  and  peroneal  as  they  cross  the 
ankle. 

The  arteries  of  the  surface  of  the  trunk  most  likely  to  produce  danger- 
ous hemorrhage  are  the  internal  mammary,  the  intercostals,  and  the 
deep  epigastric.  These  can  be  controlled 
temporarily  only  by  direct  pressure,  either 
with  the  linger  or  gauze  packing.  The 
method  of  compressing  the  intercostal  is 
represented  in  Fig.  53.  \\     ]l 

EPISTAXIS. 
Epistaxis  is  a  form  of  hemorrhage  often 

,  ,  ,  .   .  .    ,  Fig.     S3. — Tamponing    the 

troublesome      and      requiring     Special     treat-       intercostal  artery.     R,  ribs;  A, 

.  artery;  W,  gauze.  (Walskom.) 

ment.     It  may  occur  in  one  or  both  nostrils. 

The  simpler  cases  are  relieved  by  the  erect  position,  holding  the  arms 
above  the  head,  by  the  reflex  effects  of  cold  to  the  back  of  the  neck,  or 
by  pressure  over  the  root  or  sides  of  the  nose. 

If  these  measures  fail,  the  nostril  may  be  syringed  with  certain 
solutions:  hot  water;  antipyrin,  5  to  10  per  cent.,  which  is  especially 
recommended  in  the  Am.  Text-Book  of  Surgery;  adrenalin,  1  to  1000. 
The  patient  must  not  blow  his  nose,  as  this  eliminates  the  clot. 
In  the  more  severe  cases  try  tamponing  the  anterior  nares.  If  a  nasal 
speculum  and  a  good  mirror  light  are  available,  the  anterior  nares  may 
be  systematically  plugged  through  the  speculum  with  adrenalin  gauze  ; 
or,  by  such  means,  the  bleeding  point  may  be  discovered  and  loin  hed 
with  the  point  of  the  cautery,  with  silver  nitrate,  or  with  chromic  acid. 

The  International  Journal  of  Surgery  gives  this  practical  suggestion: 
a  layer  of  cotton  is  wound  around  a  pen  holder  until  the  desired  thick- 
ness is  obtained  and  then  withdrawn.  The  cotton  cylinder  is  then 
moistened,  Squeezed  dry,  and  inserted  into  the  nasal  cavity.  If  the 
projecting  end  is  now  moistened,  it  will  swell  up  and 'thus  produce 
sufficient  compression. 
5 


66 


HEMORRHAGE. 


If  these  various  measures  fail,  then  the  posterior  nares  must  be 
plugged.  For  this  purpose,  in  emergencies,  an  ordinary  soft  rubber 
catheter  is  available,  in  lieu  of  the  Bellocq  cannula  (Fig.  54).  It  is 
threaded  and  passed  directly  backward  through  the  inferior  meatus  un- 
til its  point  emerges  below  the  soft  palate.  The  thread  is  caught  with 
forceps,  drawn  out  through  the  mouth,  and  held  while  the  catheter  is 
withdrawn.  One  end  of  the  thread  projects  from  the  nostril  and  the 
other  from  the  mouth,  and  a  pledget  of  cotton  is  tied  to  this  latter  end 


Fig.  54. — Tamponing  posterior  nares.     {Stewart.) 


and  traction  made  on  the  other,  by  which  means  the  tampon,  guided  by 
the  index  finger,  is  drawn  up  behind  the  soft  palate  and  into  the  pos- 
terior nares.  When  the  tampon  is  tied  on  it,  it  is  a  good  plan  to  leave 
the  thread  still  long  enough  to  hang  out  of  the  mouth,  which  will 
greatly  facilitate  the  removal  of  the  plug;  otherwise  forceps  are  re- 
quired or  else  the  tampon  will  have  to  be  pushed  backward  into  the 
pharynx.  Any  plug  put  into  the  anterior  nares  must  be  secured  by  a 
silk  thread,  lest,  becoming  dislodged,  it  may  drop  into  the  larynx.  The 
plugs  must  not  be  left  in  for  more  than  two  days,  and  should  be 
moistened  before  removal  with  a  mild  antiseptic  solution.  Hertzfeld 
(J.  A.  M.  A.?  March  13,  1909)  describes  a  case  of  serious  hemorrhage 


ik i  \r\ii  Niui     i  i'i-i wis.  67 

from  the  nasal  cavity  treated  with  perborate  of  soda.  A  strip  of  moist 
bprated  gauze  i/a  inch  wide  was  covered  with  powdered  perborate  of 
soda  and  packed  tightly  into  the  anterior  nares.  The  hemorrhage 
ceased  immediately.  The  perborate  may  be  insufflated  directly  into 
the  cavity.  A  grayish-white  foam  immediately  issues,  nascent  oxygen 
is  liberated,  and  the  bleeding  checked. 


CHAPTER  IX. 
WOUNDS.     GENERAL  PRINCIPLES. 

DEFINITIONS. 

A  wound  is  the  solution  of  the  continuity  of  the  soft  tissues,  due 
to  trauma. 

(a)  Subcutaneous  wounds  are  traumatic  lesions  of  the  deeper  tissues 
without  any  definite  break  in  the  skin.  Such  wounds  are  more 
commonly  called  "contusions." 

(b)  Open  wounds  are  those  accompanied  by  a  solution  of  con- 
tinuity of  the  integuments. 

i.  Incised  wounds  are  open  wounds  produced  by  sharp  or  edged 
instruments. 

2.  Stab  wounds  are  those  produced  by  sharp-pointed  instruments. 

3.  Punctured  wounds  are  those  produced  by  blunt-pointed  instru- 
ments. 

"  4.  Lacerated  wounds  are  those  produced  by  tearing  or  crushing. 

5.  Gunshot  wounds  are  those  produced  by  projectiles;  shot,  bullets, 
cannon  balls. 

A  penetrating  wound  is  one  in  which  the  vulnerating  instrument 
reaches  a  body  cavity. 

A  perforating  wound  is  one  in  which  the  vulnerating  body  passes 
through  the  cavity. 

An  aseptic  wound  is  one  in  which  there  is  an  absence  of  the  germs 
of  inflammation. 

A  septic  or  infected  wound  is  one  in  which  the  germs  of  inflammation 
are  present. 

A  poisoned  wound  is  one  in  which  some  agent  destructive  to  tissue 
is  present. 

An  operative  wound  is  one  produced  by  the  surgeon's  knife,  and  is 
presumed  to  be  aseptic. 

68 


-i  B<  i   i  wi  OUS    WOUNDS.  69 

SYMPTOMS  AXIi  CHARACTERISTICS  OF  WOUNDS. 

All  wounds  produce  more  or  less  pain,  hemorrhage,  and  loss  of 
Function;  in  addition,  the  severer  wounds  produce  constitutional 
disturbances,  such  as  shock,  although  shock  may  also  occur  in  slight 
wounds.  Hemorrhage  depends  upon  the  number  and  size  of  the 
blood  vessels  involved;  pain,  upon  the  character  of  the  tissue  and  the 
extent  of  nerve  injury;  loss  of  function,  upon  the  amount  and  kind 
of  tissue  destroyed;  shock,  upon  the  mode  of  injury  and  the  tissues 
concerned. 

Subcutaneous  wounds  vary  widely  in  the  amount  of  tissue  divided. 
There  may  be  any  degree,  from  a  mere  strain  of  a  few  fibers,  with 
slight  intercellular  exudation  (bruises),  to  total  division  or  widespread 
laceration  of  the  various  layers  of  subcutaneous  tissue. 

The  pain  is  dull  and  aching.  The  hemorrhage  is  usually  slight,  but 
occasionally  may  be  dangerous.  If  the  hemorrhage  is  slight,  it  pro- 
duces merely  subcutaneous  discoloration,  most  marked  in  lax  tissues; 
if  moderate,  it  produces  an  ecchymosis;  if  serious,  a  hematoma. 

Contusion  of  the  nerves  may  produce  paralysis,  usually  temporary; 
or  the  nerve  may  be  completely  divided  in  subcutaneous  wounds, 
and  the  paralysis  be  permanent.  Shock  is  nearly  always  present  in 
some  degree. 

Treatment. — Subcutaneous  wounds  are  nearly  always  aseptic,  and 
an  effort  should  be  made  to  keep  them  so. 

The  first  principle  of  treatment  is  functional  rest.  It  may  be  secured 
in  bed,  or  by  the  use  of  splints,  slings,  or  bandages.  Mere  voluntary 
immobilization  is  not  often  sufficient.  Apply  a  cotton  compress  and 
bandage;  a  flannel  bandage  firmly  laid  on,  alone,  often  gives  great 
relief.  Evaporating  lotions,  in  the  case  of  superficial  contusions, 
often  do  good.  Tincture  of  arnica  and  witch  hazel  are  common 
domestic  remedies. 

The  following  solution,  freely  and  immediately  applied,  will  often 
prevent  a  "  blacked  "  eye. 

ty — Ammoni.  chloridi.,  gr.  v. 

Alcohol,  ."»      i. 

Cold,  while  often  giving  relief,  must  be  used  with  caution,  since  .1 


7° 


WOUNDS.      GENERAL   PRINCIPLES. 


too  long  application  will  lower  the  vitality  of  the  tissues  and  interfere 
with  repair,  or  will  even  precipitate  death  of  the  injured  tissues. 
Heat,  in  the  form  of  a  hot  water  bottle  or  hot  flannels,  is  better. 
If  the  extravasations  of  blood  are  moderate,  they  may  be  let  alone; 
or  if  persistent  and  interfering  with  repair,  they  may  be  aspirated. 
In  either  event,  after  the  inflammatory  symptoms  have  subsided, 
massage  is  useful  to  hasten  absorption,  promote  nutrition,  and  insure 
repair  and  restoration  of  function. 

In  those  cases  of  severe  injury,  where  the  subcutaneous  hemorrhage 
is  marked  and  continuous,  and  where  a 
hematoma  forms,  the  skin  must  be  incised 
without  delay,  the  clots  turned  out,  the 
wounded  vessels  secured,  and  the  wound 
subsequently  treated  as  an  open  one. 

Incised  wounds  are  characterized  by 
sharp  and  severe  pain,  free  bleeding,  and  a 
tendency  to  gape. 

The  slight  actual  destruction  of  tissue,  the 
comparative  cleanliness  of  a  cutting  instru- 
ment, the  free  bleeding,  and  the  gaping 
present  conditions  most  favorable  for  trans- 
forming an  infected  wound  into  an  aseptic 
one,  or  at  least  practically  so.  At  any  rate, 
many  presumably  infected  incised  wounds 
heal  with  the  same  readiness  and  absence  of 
inflammatory  symptoms  as  aseptic  opera- 
tive wounds. 
Treatment. — For  the  arrest  of  hemorrhage,  ordinarily,  a  compress 
wrung  out  of  hot  water  or  normal  salt  solution  is  sufficient.  If 
this  does  not  have  the  desired  result,  the  bleeding  vessels  are  to  be 
seized  with  artery  forceps  and  ligated.  The  hemostasis  must  be 
complete. 

The  wound  is  next  carefully  cleansed  of  clots  and  foreign  bodies, 
using  normal  salt  solution,  sterile  water,  or  very  weak  antiseptic 
solutions.  Under  favorable  circumstances,  that  is  to  say,  if  there  is  a 
reasonable  certainty  that  the  wound  has  been  rendered  practically 


Fig.  55. — Repair  of  in 
fected  incised  wound  of  thigh 
(Veau.) 


OPERATIVE    WOUNDS. 


71 


sterile,  it  is  closed.  If  sepsis  is  feared,  a  small  tube  or  capillary  drain 
must  be  employed  (Kig.  55). 

In  the  first  instance,  the  wound  is  as  carefully  closed  by  suture  as 
an  operative  one.  In  the  second  case,  sutures  are  employed,  but 
are  placed  further  apart,  leaving  the  wound  free  of  access  for  cleansing 
solutions  and  for  the  free  escape  of  the  exudates.  If  drainage  is 
employed,  it  may  usually  be  dispensed  with  after  the  third  day,  if  no 
sepsis  arises. 

It  is  safer  to  regard  all  large  incised  wounds  as  infected.  If  the 
wound  is  closed,  it  must  be  carefully  watched  for  signs  of  infection, 
and,  on  their  appearance,  be  reopened  without  delay;  or  the  sutures 


Fig.  56. — Method  of  making  an  incision.     (Veau.) 


may  be  placed  and  left  untied  until  the  probabilities  of  infection  have 
been  determined.  A  wound  sealed  on  the  surface  and  infected  below 
is  a  calamity. 

After  repair  of  the  aseptic  incised  wound,  a  dressing  of  plain  sterile 
or  borated  gauze  is  applied,  and  over  this  absorbent  cotton  and 
bandage. 

In  certain  instances,  as  with  incised  wounds  of  the  face,  the  dressing 
may  be  dispensed  with,  the  slight  serous  exudate  being  allowed  to  dry 
and  form  a  crust,  which  protection  is  quite  adequate. 

Operative  wounds  are  incised  wounds,  and  the  aim  is  always  to 
make  and  maintain  them  aseptic.  Aside  from  preliminary  steriliza- 
tions, there  is  a  proper  method  of  making  these  wounds,  which  is 
essential  in  keeping  them  aseptic  and  promoting  repair. 


72  WOUNDS.       GENERAL   PRINCIPLES. 

The  aim  should  be  to  do  as  little  violence  as  possible  to  any  tissues 
incised.  The  cutting  instrument  must  be  sharp,  and  the  tissues 
evenly  and  smoothly  divided. 

To  make  a  good  incision,  fix  and  slightly  stretch  the  tissues  on  either 
side  of  the  proposed  line  of  section,  with  the  left  thumb  and  index 
finger.  Never  put  the  skin  on  the  stretch  on  one  side  only.  The 
first  stroke  of  the  scalpel  should  divide  the  skin  for  the  whole  length 


Fig.  5  7. — A  good  incision.      (Veau.) 

previously  determined  (Fig.  56).  Determine  beforehand  the  lengtrT 
of  incision  required.  The  inexperienced  operator  is  inclined  to  make 
the  wound  too  short  but  it  may  be  subsequently  lengthened.  When 
the  skin  and  subcutaneous  connective  tissue  are  divided,  identify  the 
deep  fascia  before  incising  it;  it  is  an  important  land-mark  in  nearly 
every  part  of  the  body.  All  the  layers  must  be  cut  without  any  gashing 
or  notching.     The  incision  in  the  deeper  layers  should  not  be  quite  so 


4.M 

Fig.  58. — A  bad  incision.     (Veau.) 

long  as  in  the  superficial  layer.  The  good  incision  gives  an  equally 
good  view  of  all  parts  of  the  cavity  (Fig.  57).  The  bad  incision 
creates  irregularities  which  interfere  with  inspection,  not  to  speak  of 
repair  (Fig.  58). 

Stab  wounds  differ  from  incised  wounds  only  in  their  greater 
uncertainties.  Their  narrowness  and  depth  make  it  difficult  to 
determine  what  organs  and  tissues  have  been  involved. 


i  \(  i  r  \  1 1  d   \\"i  \i'S.  73 

In  order  to  make  a  doubtful  diagnosis  sure,  to  repair  an  injured 
structure,  t<>  control  hemorrhage,  and,  to  insure  antisepsis,  it  is  often 
accessary  to  enlarge  the  wound.  In  other  respects  these  wounds  are 
treated  on  the  same  general  principles  as  incised  wounds. 

Punctured  wounds  are  peculiarly  a  source  of  worry.  They  are 
most  prone  to  become  septic  for  two  reasons;  first,  infection  is  very 
likely  to  he  carried  into  the  wound,  and,  second,  it  is  likely  to  be 
retained. 

The  vulnerating  instrument  is  usually  unclean;  portions  of  it  may 
he  broken  off  and  retained;  other  foreign  bodies,  such  as  shreds  of 
clothing,  sources  of  infection,  may  be  pushed  in  and  overlooked,  in- 
asmuch as  the  narrow  tract  makes  exploration  difficult.  The  tissues 
are  not  divided,  hut  are  pushed  apart,  and  tend  to  close  as  the  instru- 
ment is  withdrawn:  The  vessels  are  little  wounded,  so  that  bleeding, 
the  best  agent  for  disinfection,  for  washing  out  the  invading  micro- 
organisms, is  wanting. 

The  bottom  of  these  wounds  may  be  shut  off  from  the  surface,  so 
that  the  oxygen-hating  bacillus  of  tetanus  finds  there  a  congenial 
lodging. 

The  Ircalmml,  for  all  these  reasons,  must  be  circumspect.  In  doubt- 
ful cases,  it  is  better  at  once  to  lay  open  the  wound  and  thoroughly 
disinfect  and  search  for  foreign  bodies.  In  any  event,  the  wound 
must  he  carefully  syringed  with  cleansing  solutions.  Peroxide  of 
hydrogen  is  particularly  indicated  if  tetanus  is  anticipated.  If  sup- 
puration is  threatened,  early  and  free  incision  and  drainage  are 
imperative. 

Counter  openings  may  be  required  to  facilitate  the  removal  of  foreign 
bodies  or  inflammatory  products. 

Lacerated  wounds  are  characterized  by  the  great  destruction  of 
tissue,  comparatively  speaking.  "They  are  peculiarly  the  product 
of  modern  times."  The  machinery  of  rapid  transit  and  manufactory 
is  largely  responsible.  Boiler  explosions  contribute  a  number.  Gun- 
shot wounds,  especially  of  the  face,  are  likely  to  he  Lacerated  wounds. 

The- manner  in  which  the  injuries  are  produced,  the  tearing  and 
crushing  of  the  tissues,  gives  such  injuries  the  following  character- 
istics: 


74  WOUNDS.      GENERAL   PRINCIPLES. 

(i)  There  is  slight  primary  hemorrhage. 

(2)  There  is  frequently  reactionary  or  secondary  hemorrhage. 

(3)  Shock  is  usually  present. 

(4)  Infection  seldom  fails  to  develop. 

(5)  Deformity  is  likely  to  result. 
The  following  are  the  reasons: 

(1)  Primary  hemorrhage  is  slight,  out  of  all  proportion  to  the 
destruction  of  tissue,  because  the  coats  of  the  torn  vessels  curl  up  and 
contract,  the  ragged,  uneven  surfaces  favor  coagulation,  and  the 
presence  of  shock  lowers  the  blood  pressure. 

(2)  Reactionary  hemorrhage  occurs  because  of  the  smaller  vessels 
losing  their  plugs  of  clotted  blood  when  the  blood  pressure  is  restored. 
Secondary  hemorrhage  occurs  because  of  the  suppuration,  which  is 
the  rule  rather  than  the  exception,  unless  prevented  by  treatment. 

(3)  Shock  is  always  present  in  some  degree  because  of  the  injuries 
to  the  nerve  trunks.  In  crushing  injuries  to  the  extremities,  it  is 
sometimes  difficult  to  relieve  shock  until  the  mangled  nerves  are 
completely  divided  by  amputation.  Sometimes  under  these  circum- 
stances, the  shock  is  immediately  fatal. 

(4)  Infection  is  coincident  with  the  injury  because  of  the  grime 
which  is  ground  into  the  tissues.  The  vitality  of  the  tissues  adjoining 
those  which  were  killed  outright  is  greatly  lowered,  and  the  power  to 
resist  microbic  invasion  lost.  An  invading  germ  and  lowered  vitality 
are  the  two  factors  always  essential  to  suppuration. 

Treatment  of  Lacerated  Wounds. — (1)  Hemostasis,  (2)  relief 
of  shock,  (3)  antisepsis,  (4)  support. 

(1)  Hemostasis  is  usually  not  difficult.  It  may  be  necessary  to 
catch  up  a  bleeding  vessel  with  forceps  and  ligate,  but  more  often 
pressure  with  gauze  pads  wrung  out  of  hot  normal  salt  solution  suffices. 
Unless  the  hemorrhage  is  severe,  sterilize  the  adjacent  skin  with  soap 
and  water,  bichloride,  or  alcohol,  before  beginning  exploration. 

(2)  Shock  is  treated  on  general  principles.  Maintain  the  body 
heat,  lower  the  head,  and  keep  the  patient  quiet.  In  severe  cases, 
injections  of  adrenalin  and  salt  solution  are  to  be  employed:  (See 
shock.) 

(3)  Antiseptic  measures  follow  the  arrest  of  hemorrhage  and  shock. 


TREATMENT    OF    LACERATED    WOUNDS.  75 

Begin  by  covering  the  wound  with  sterile  gauze,  and  dun  scrub  the 
adjacent  skin  with  soap  and  sterile  water,  then  with  bichloride,  1-2000, 
and  finally  with  alcohol.  Next  cleanse  the  wound.  By  repeatedly 
flushing  with  normal  salt  solution  or  very  weak  bichloride  or  other 
antiseptics,  an  effort  is  made  to  rid  the  tissues,  as  much  as  possible,  of 
dirt  and  debris. 

Porter,  of  Fort  Wayne,  says  with  regard  to  cleansing  wounds  (Amer- 
ican Medicine,  September,  "  1906),  that  it  is  an  easy  matter  to 
overdo  in  our  attempts  to  render  an  accidental  wound  aseptic.  By 
the  use  of  too  vigorous  scrubbing,  too  harsh  mechanical  means, 
too  hot  water,  or  too  strong  antiseptic  solutions,  more  harm  than  good 
may  be  done.  The  resisting  power  of  the  tissues  is  perhaps  the  most 
potent  single  factor  in  preventing  infection,  and  it  may  be  diminished 
by  too  much  antiseptic  zeal.  We  must  remember  that  in  spite  of  our 
efforts  some  germs  will  be  left  for  nature  to  take  care  of,  and  we  must 
not  make  it  impossible  for  her  to  do  it.  "Personally,"  says  Porter, 
"I  find  myself  using  more  care,  more  time,  more  patience,  more  soap, 
more  water,  and  less  vigorous  scrubbing,  less  curettement,  and  weaker 
germicides."  The  grime  and  grease  of  machinery  are  most  readily 
removed  by  pouring  on  gasoline. 

It  is  not  always  possible  to  determine  to  what  extent  the  tissues  are 
fatally  injured.  In  the  case  of  crushed  wounds  of  the  extremities, 
it  may  be  necessary  to  wait  until  a  line  of  demarcation  appears,  so 
that  no  useful  tissues  shall  be  unnecessarily  sacrificed. 

Drainage  is  a  matter  of  antisepsis.  It  is  a  sine  qua  mm  in  the  case 
of  lacerated  or  crushing  wounds,  but  there  is  usually  little  trouble  in 
this  respect  for  the  reason  that  these  wounds  are  not  sutured  and 
drainage  is  provided  for  in  the  dressing. 

(4)  Suture  of  the  skin  wound  is  not  possible,  as  a  rule,  but  certain 
of  the  deeper  structures  may  demand  such  repair.  A  divided  nerve 
trunk,  tendon,  or  muscle  requires  approximation.  Sometimes  coapta- 
tion of  the  wound,  even  though  incomplete,  will  lessen  the  time 
required  for  granulation. 

The  dressing  must  fill  two  requirements;  it  must  absorb  the  dis- 
charge and  also  keep  out  infection.     The  most  commonly  employed 

dressing  consists  of  a  loose  but  lil>eral  covering  of  bichloride  «>r  borated 


76  WOUNDS.       GENERAL   PRINCIPLES. 

gauze  applied  to  the  wound,  and  over  this  a  covering  of  absorbent 
cotton  held  in  place  by  a  bandage,  which  is  applied  for  the  purpose 
also  of  giving  equal  pressure  and  support  to  the  wounded  tissues. 
The  frequency  with  which  the  dressing  must  be  changed  will  depend 
upon  the  degree  of  infection. 

The  author  has  derived  much  satisfaction  in  the  treatment  of  this 
class  of  wounds  from  the  use  of  the  ointment  mentioned  on  page  409. 
After  the  wound  has  been  cleansed,  the  ointment  is  applied  and  the 
whole  covered  with  gauze  and  bandaged.  It  tends  to  relieve  tension 
and  pain  and  promote  repair.  The  gauze  does  not  adhere  to  the 
surface  of  the  wound  and  so  the  change  of  dressing  is  facilitated. 

The  aim  in  general  is  to  disturb  the  tissues  as  little  as  possible, 
and  no  change  is  made  except  to.  meet  the  indications  of  some  phase 
of  sepsis. 

Infected  wounds  may  not  be  recognized  as  such  from  the  first,  but 
soon  the  processes  of  inflammation  manifest  themselves.  Pain,  red- 
ness and  swelling,  accompanied  by  certain  constitutional  states,  such 
as  fever  and  rapid  pulse,  are  the  cardinal  symptoms. 

The  sepsis  may  produce  no  results  more  severe  than  temporary 
disturbances  of  the  character  named.  On  the  other  hand,  it  may 
result  in  suppuration,  which  prolongs  repair  and  produces  unwelcome 
cicatrices;  or,  even  worse,  the  infection  may  spread  so  rapidly  as  to 
involve  extensive  areas,  rendering  the  tissues  brawny  with  serous 
exudates  and  overwhelming  the  heart  and  kidneys  with  toxins  before 
suppuration  has  time  to  appear.  It  is  these  uncertainties  which 
make  infection  so  much  to  be  feared,  and  make  its  prevention  the 
largest  element  in  the  treatment  of  ordinary  wounds.  When  once  the 
sepsis  has  a  definite  foothold  in  a  wound,  the  treatment  has  two  objects: 
to  destroy  the  germ  and  remove  and  neutralize  its  toxins;  and  to  sup- 
port the  tissues  in  their  struggle. 

Irrigate  the  wound  cavity  at  least  once  daily  with  weak  antiseptic 
solutions,  such  as  bichloride,  peroxide,  lysol,  or  iodine;  provide  the 
freest  exit  for  the  exudates,  employing  drainage  tubes,  if  there  is  a 
cavity.  Never  pack  a  suppurating  cavity  with  gauze.  Apply  a 
moist  gauze  dressing,  moistening  it  with  alcohol,  bichloride  or  boric 
acid,  or  other  antiseptic  solutions,  or,  what  is  perhaps  as  well,  with 


INFECTED    WOUNDS.  77 

normal  salt  solution.  This  may  or  may  aol  be  i  overed  with  absorbent 
cotton.  Whatever  other  qualities  the  dressing  may  possess,  it  must 
be  absorbent.  Sometimes  in  the  case  of  the  extremities,  prolonged 
immersion  in  warm  normal  salt  solution  dot's  good. 

After  granulation  once  begins,  it  may  be  stimulated  and  the  wound 
kept  healthy  by  the  use  of  dusting  powders,  antiseptic  ointments, 
or  balsam  of  Peru.  The  latter  has  been  lately  very  highly  recom- 
mended, in  the  treatment  of  wounds  generally. 


CHAPTER  X. 
WOUNDS  OF  SPECIAL  REGIONS. 

WOUNDS  OF  THE  SCALP. 

Certain  anatomical  features  determine  the  special  character  of 
scalp  wounds,  and  must  be  kept  in  mind  in  prognosis  and  treatment. 

The  blood  vessels  converge  toward  the  vertex;  they  are  the  occipital, 
posterior  auricular,  superficial  temporal,  supraorbital  and  temporal, 
any  one  of  which  may  give  rise  to  troublesome  bleeding,  and  all  of 
which  are  subcutaneous  instead  of  subaponeurotic,  as  elsewhere. 

They  are  firmly  connected  with  the  dense  tissue  of  the  scalp  and 
for  that  reason  do  not  readily  contract  when  divided;  for  this  reason 
the  bleeding  from  scalp  wounds  is  copious  and  without  much  tendency 
to  spontaneous  arrest.  The  vessels  are  somewhat  difficult  to  catch 
with  artery  forceps. 

The  aponeurosis  of  the  occipito-frontalis  is  the  dividing  line  in 
prognosis:  wounds  that  do  not  penetrate  it  are  less  likely  to  become 
infected,  nor  do  the  conditions  favor  spread  of  infection.  A  wound 
perforating  the  aponeurosis  is  always  a  matter  of  concern ;  for,  owing 
to  the  loose  cellular  tissues  which  connect  the  aponeurosis  with  the  peri- 
cranium, an  infection  may  spread  very  rapidly  and  in  every  direction. 

All  scalp  wounds  are  presumably  infected,  yet  the  free  bleeding 
minimizes  the  infection,  and  the  rich  blood  supply  of  the  tissues  favors 
rapid  repair. 

Scalp  wounds  do  not  gape  unless  the  aponeurosis  is  divided,  and 
contused  wounds  often  resemble   incised  wounds. 

Contusions  may  result  in  the  formation  of  hematoma  beneath  the 
skin,  but  they  are  of  little  moment.  Evaporating  lotions  are  sufficient 
to  hasten  absorption. 

A  severer  injury  may  cause  a  hematoma  under  the  aponeurosis. 
Glancing  blows,  other  things  being  equal,  are  more  likely  to  cause 
the  tumors,  rupturing  the  vessels  of  the  subaponeurotic  areolar  tissue. 
Such  a  tumor  is  likely  to  be  extensive.     It  may  be  the  source  of  error 

78 


oi'KN    WOUNDS    OF    SCAM'.  79 

in  diagnosis,  giving  the  examining  finger  the  sensation  of  a  depn 
fracture,  being  hard  around  the  borders,  and  soft  in  the  center.     U  the 
tumor  is  of  such  size  as  to  put  the  skin  greatly  od  the  stretch,  it  may  be 

punctured.     This  is  preferable  to  incision,  for  there  is  less  chance  of 
infecting  the  exudate. 

Absorption  always  takes  place  so  thai  the  least  interference  possible- 
is  the  best  treatment. 

A  hematoma  may  form  under  the  pericranium,  usually  in  children 
in  whom  the  bone  has  a  rich  vascular  supply.  Here,  also,  it  is  ab- 
sorbed in  time,  and  intervention  is  rarely,  if  ever,  necessary. 

Open  Wounds. — The  treatment  of  these  wounds,  of  whatever 
character,  may  be  expressed  in  certain  general  formulae. 

The  first  step  consists  in  cleansing  the  hair  of  the  blood,  which  is 
not  always  an  easy  task.  Warm  water  is  best  to  dissolve  out  the  clots, 
or  peroxide  of  hydrogen. 

The  next  step  consists  in  removing  more  or  less  of  the  hair,  depend- 
ing upon  the  gravity  of  the  wound.  In  all  serious  cases,  the  whole 
scalp  must  be  shaved.  Begin  by  cutting  the  hair  with  the  scissors, 
and  then  apply  the  razor;  the  "safety  razor"  facilitates  this  work. 

Next  cleanse  the  scalp  with  ether,  to  dissolve  the  oil  which  is  always 
present,  and  follow  this  with  alcohol;  otherwise  the  ether  will  interfere 
with  the  soap  and  water  cleansing  which  follows,  and  which  is  freeh- 
and vigorously  applied. 

In  the  meantime,  a  light  gauze  packing  prevents  the  soap  and 
water  running  into  the  wound.  Once  the  scalp  is  cleansed,  Un- 
wound itself  is  to  be  cleansed. 

Strong  antiseptics  are  distinctly  to  be  avoided.  Sterile  water, 
normal  salt  solution,  or  peroxide  are  perhaps  the  best.  An  irrigator 
or  syringe  is  not  to  be  used,  but  the  solution  may  be  squeezed  out  of  a 
compress  into  the  wound.  Be  assured  that  every  particle  of  foreign 
matter  is  out  of  the  wound  before  considering  repair. 

Complete  hemostasis  is  an  essential  to  rapid  healing,  and  the  time 
and  patience  spent  in  securing  it  are  by  no  means  lost.  If  the  bleeding 
vessels  cannot  be  ligated  in  the  ordinary  way,  the  ligature  may  be 
carried  on  a  needle  through  the  tissues  surrounding  the  vessel.  The 
oozing  may  be  entirely  controlled  by  a  few  minutes'  pressure  with  a 


80  WOUNDS    OF   SPECIAL    REGIONS. 

hot  antiseptic  compress.  The  main  thing  is  not  to  get  discouraged  or 
be  in  too  great  a  hurry. 

The  cleansing  and  hemostasis  completed,  the  coaptation  follows. 
In  the  case  of  contused  wounds,  the  ragged  edges  are  to  be  trimmed 
away.  The  suturing  is  an  important  step  in  facilitating  reunion. 
Even  wounds  that  do  not  gape  heal  all  the  more  quickly  for  suturing, 
silk  being  probably  the  best  material. 

In  many  cases  of  incised  wounds  which  are  not  deep,  the  suturing 
may  be  firm  and  no  drainage  required.  In  the  great  majority  of  cases, 
however,  drainage  is  necessary,  and  may  be  secured  by  incomplete 
suture,  by  a  tube,  or,  following  Von  Bergman,  by  strips  of  gauze. 

If  a  large  segment  of  the  scalp  has  been  loosened,  every  effort  must 
be  made  to  readjust  and  suture  it  accurately,  though  the  drainage 
must  be  ample.  Oftentimes  with  those  who  have  been  even  almost 
completely  scalped,  the  results  have  been  excellent. 

The  dressing  will  usually  consist  of  sterile  gauze  and  absorbent 
cotton  held  in  place  by  bandage.  In  the  case  of  minor  wounds,  and 
where  no  infection  is  feared,  it  is  sufficient  to  smear  the  line  of  suture 
with  sterile  vaseline  and  cover  with  flexible  collodion. 

WOUNDS  OF  THE  PINNA. 

Many  forms  of  injury  befall  the  ear.  It  may  be  bruised,  cut,  or 
lacerated,  and  much  or  little  of  it  lost.  Even  a  slight  loss  is  a  dis- 
figurement, and  any  very  serious  loss  of  tissue  results  also  in  some 
disturbance  of  hearing. 

A  laborer  came  into  the  City  Dispensary  with  half  an  ear  cut  off 
and  hanging  by  a  mere  thread  of  tissue.  The  sharp  edge  of  a  spade 
wielded  by  a  co-worker  had  produced  the  injury.  The  almost  dis- 
carded member  was  carefully  sutured  in  place  with  silk.  Some 
sloughing  occurred  along  the  edges  of  the  wound  but  eventually  the 
repair  was  complete  and  almost  without  a  scar. 

These  tissues  possess  great  vitality,  and  the  completeness  of  repair 
after  much  mutilation  is  often  surprising.  Large  portions  of  the 
ear  may  be  cut  off  completely,  and  yet  if  immediately  sutured  in 
careful  coaptation,  union  will  occur.  There  may  be  some  sloughing 
along  the  line  of  union,  but  eventually  there  is  but  little  scar  tissue  left. 


win  \i>s   OP   THE    Ill's. 


81 


In  every  case,  then,  of  incised  wound,  an  effort  must  be  made  i<> 
suture.     The  hemostasis  must  be  complete,  and   if  there  is  much 

laceration,  the  edges  of  the  wound  must  be  trimmed.      Silk  is  the  besl 
suture  material  in  these  cases. 

WOUNDS  OF  THE  FACE. 

Accidental  wounds  of  this  region,  more  than  any  others,  approxi- 
mate aseptic  wounds.  These  wounds  do  not  gape  much;  the  tissues 
are  very  vascular,  so  that  the  conditions  are  most  favorable  for  repair. 
The  chief  aim  is  to  avoid  scar  tissue  and  the  consequent  disfigurement. 
To  attain  that  end  the  suturing  must  be  delicate,  the  coaptation  per- 
fect.    The  sutures  must  be  as  small  as  possible  and  as  few  as  possible. 

The  subcutaneous  stitch  may  be  employed  if  the  wound  is  extensive 
and  dee]).  In  ordinary  incised  wounds  extensive  dressings  may  be 
dispensed  with,  and  the  line  of  suture  may  be  covered  with  collodion  or, 
as  Von  Bergman,  who  dislikes  collodion,  suggests,  the  wound  may  be 
amply  protected  by  the  scab  formed  by  the  dried  exudates. 

WOUNDS  OF  THE  LIPS. 

Wounds  of  the  lips  are  likely  to  bleed  considerably,  but  the  hemor- 
rhage is  easily  controlled  by 
compressing  the  lip  between  the 
thumb  and  index  linger,  and 
then  the  coronary  artery  may  be 
Iigated  on  each  side  of  the  wound. 

When  the  division  is  complete, 
begin  the  repair  by  suturing  the 
mucous  membrane  (Fig.  59) 
with  catgut.  Suture  the  skin  by 
continuous  or  interrupted  suture 
of  tine  silk  or  catgut.  The 
greatest  care  must  be  exercised 
when  the  border  of  the  lip  is 
reached;  the  coaptation  must  be 
exact  or  the  result  will  be  a  disappointment. 

A  small  drain  in  the  skin  wound  is  usually  advisable. 
6 


FlG.  59. — Suturing  wound  of  lip.    {Vtau.} 


82  WOUNDS    OF   SPECIAL   REGIONS. 

WOUNDS  OF  THE  TONGUE. 

Wounds  of  the  tongue,  which  are  not  as  infrequent  as  one  might 
expect,  may  give  rise  to  a  disagreeable  hemorrhage. 

The  tongue  is  to  be  drawn  out  of  the  mouth  and  compressed  with 
the  fingers  above  the  wound  or  by  a  pair  of  forceps  covered  with 
rubber  tubing  or  with  gauze.     (Fig.  60.) 


-Suturing  wound  of  tongue.     A,  tongue  controlled  by  tenaculum  forceps.     _B,  fi 
passed  and  tied.     C,  second  suture  passed,  using  the  Reverdin  needle.     {Lejars.. 


Suture  the  bleeding  points,  employing  deep  sutures  of  catgut,  No.  3. 
Every  quarter  hour  the  mouth  should  be  washed  with  a  solution  of 
chloral,  2  grains  to  the  ounce,  until  the  oozing  and  pain  have  subsided. 

WOUNDS  OF  THE  EYE-LID. 

A  wound  of  the  eye-lid  is  to  be  repaired  like  a  wound  of  the  lip,  by 
two  lines  of  suture.  First  suture  the  mucous  membrane  with  fine 
catgut.     Then  begin  the  suture  of  the  skin  at  the  free  border,  where 


WOUNDS   OF    Till.    M  ik. 


83 


the  edges  oi  the  divided  tarsal  cartilage  are  to  be  very  accurately 
coapted  (Fig.  61).  If  drainage  is  used,  it  must  be  small  and  proje<  1 
from  the  middle  of  the  wound. 


WOUNDS  OK  THF  NECK. 

One  has  but  to  consider  the  multiplicity  of  the  structures  in  the  neck 
to  realize  that  wounds  of  this  region  are  likely  to  be  complicated. 

Whether  the  wound  be  incised  or  contused,  a  stab  or  a  gunshot 
wound,  there  are  the  dangers  that  arise  from  hemorrhage,  asphyxia, 
and  infection. 

The  most  common  wounds,  per- 
haps, are  those  which  arise  from 
attempts  at  suicide.  That  these 
attempts  are  often  abortive,  and  the 
danger  done  much  less  than  one 
might  expect,  are  due  to  the  fact 
that  the  tissues  are  yielding  and  the 
vessels  recede  as  the  head  is  thrown 
back;  the  knife  may  be  directed 
against  the  lower  jaw  or  spend  its 
force  on  the  cartilages  or  hyoid  bone;  the  arm  may  lose  its  force  at 
the  moment  the  larynx  is  opened,  or  from  failing  resolution.  In  these 
attempts  at  suicide,  the  wound  in  right-handed  people  usually  begins 
on  the  left  side  high  up,  and  runs  obliquely  downward  to  the  right, 
becoming  less  and  less  deep.  Not  infrequently  the  wound  may  appear 
jagged,  or  give  the  impression  of  two  or  three  slashes,  from  the  folding 
of  the  skin  before  the  pressure  of  the  knife  (Fig.  62). 

In  the  graver  cases,  hemorrhage  is  usually  the  first  consideration. 
If  a  carotid  is  wounded,  a  geyser  of  blood  spurts  out  and  the  patient's 
life  is  in  the  hands  of  the  first  comer,  for  there  is  no  time  to  call  for 
skilled  aid.  If  the  internal  jugular  is  wounded,  the  hemorrhage  is 
scarcely  less  dangerous  and  perhaps  even  more  difficult  definitely  to 
control.  Air  may  enter  the  venous  circulation  and  death  immediately 
ensue.     In  either  case  anything  but   intelligent   first   aid   will  fail. 

The  carotid  may  lie  controlled  by  pressure  downward  and  backward 


Fig.    61. — Incised    wound    of    upper    lid. 
Tarsal  cartilage  sutured  first,     (t 


WOUNDS    OF    SPECIAL    REGIONS. 


at  the  base  of  the  neck,  compressing  the  vessel  against  the  transverse 
process  of  the  sixth  cervical  vertebra;  or  the  bleeding  may  be  tempo- 
rarily controlled  by  direct  pressure  on  the  bleeding  vessel  in  the  wound. 


&.  Yi«*Mt 


pIG  62  — Incised  wound  of  neck  involving  the  larynx.  1,  platysma;  2,  sterno-mastoid; 
x  int  jug  vein-  4,  vagus  nerve;  5,  ext.  jugular  vein;  6,  com.  carotid  art.;  7.  upper  part  of 
wound  in  thyroid  cartilage  opening  into  larynx;  8,  sup.  thyr.  art.;  9,  st.  hyoid  muscle; 
10,  sterno-thyroid  muse. 


When  the  surgeon  arrives  upon  the  scene,  he  finds  the  wound  filled 
with  a  great  clot,  for  it  cannot  be  expected  that  the  first  aid  will  do 
anything  more  than  partly  check  the  bleeding.     His  first  effort  must 


WOUNDS    OF   Till      EYE.  85 

be  to  cleanse  out  the  dots  and  locate  both  ends  of  the  bleeding  vessels, 
clamp  them,  and  ligate.  Blind  damping  of  the  tissues  en  masse  is 
absolutely  unsurgical.  It'  the  ends  of  the  divided  vessel  cannot  be 
located,  the  wound  is  to  be  enlarged  over  the  course  of  the  vessd, 
using  the  anterior  border  of  the  sternodeidomastoid  muscle  as  a  guide. 
If  the  character  of  the  wound  or  the  region  predude  mat,  then  the 
artery  must  be  exposed  below  the  wound  and  ligated.  It  may  happen, 
especially  in  secondary  hemorrhage,  that  the  carotid  on  the  opposite 
side  also  may  need  to  be  ligated  either  temporarily  or  permanently. 
The  internal  jugular  may  be  difficult  to  expose  and  ligate  because 
of  its  thin  and  friable  walls.  Even  small  openings  in  the  vessel  may 
call  for  circular  ligation,  for  lateral  ligation  is  usually  unsatisfactory. 
Outside  of  the  hospital,  suture  can  scarcely  be  considered. 

If  the  trachea,  in  its  upper  part,  or  the  larynx  is  opened,  it  is  better 
to  do  a  tracheotomy  lower  down  and  attempt  repair  of  the  wound. 
In  many  cases,  however,  if  the  wound  is  not  extensive,  it  is  sufficient 
to  close  the  wound  by  flexing  the  neck,  omitting  the  sutures,  and 
leaving  nature  to  repair  the  opening  in  the  air  passage. 

If  the  esophagus  or  pharynx  is  perforated,  repair  should  be  at- 
tempted; but  drainage  must  be  employed  and  the  external  wound  left 
open,  for,  in  the  act  of  swallowing,  particles  of  food  may  be  forced  into 
the  wound  to  set  up  infection. 

If  infection  or  inflammation  of  the  respiratory  tract  arises,  it  is  to  be 
treated  on  general  principles. 

Divided  nerves  should  be  repaired  if  possible,  although  often  the 
difficulties  are  too  great  to  surmount. 

WOUNDS  OF  THE  EYE. 

Morrison,  of  Indianapolis  (Indiana  Medical  Journal,  Feb.,  1907), 
has  denned  the  injuries  of  the  eye,  whose  treatment  must  most  often 
be  instituted  by  the  general  practitioner.  From  the  diagnostic  point 
of  view,  he  classifies  them  under  two  heads: 

(a)  Those  without  superfit  ial  lesions  of  the  ball. 

(b)  Those  with  more  «>r  less  extensive  open  wounds'. 

(a)  The  first  may  lead  the  practitioner  into  grievous  error  in  prog- 
nosis and  injudicious  lark  of  treatment.      No  blow  over  the  eye  should 


86  WOUNDS    OF   SPECIAL   REGIONS. 

ever  be  considered  lightly.  While  the  majority  of  such  cases  lead  to 
no  serious  consequences,  the  exceptions  are  of  sufficient  frequency 
to  be  of  importance. 

It  is  possible  for  the  so-called  "concussions"  to  lead  to  subsequent 
inflammation  or  degeneration  of  the  deeper  structures  of  the  eye.  So, 
then,  though  no  treatment  is  to  be  instituted  in  the  absence  of  symp- 
toms, yet  the  case  must  be  kept  under  observation  for  some  time,  the 
vision  tested,  irregularities  of  the  pupil  noted,  and  evidences  of  in- 
flammation sought  for. 

On  the  other  hand,  there  may  be  a  hemorrhage  into  the  anterior 
or  posterior  chambers,  accompanied  by  pain,  protrusion  of  the  eye-ball, 
and  swelling  of  the  lids.  Under  such  circumstances,  put  the  patient 
to  bed  at  once  and  apply  iced  cloths  to  the  eye,  this  treatment  to  be 
kept  up  until  the  symptoms  begin  to  subside,  when  it  is  probable  that 
the  blood  has  clotted  and  the  hemorrhage  ceased. 

In  addition  to,  or  instead  of  hemorrhage,  there  may  be  disarrange- 
ment of  the  retina,  lens  or  iris,  accompanied  by  disturbance  or  destruc- 
tion of  vision. 

Put  the  patient  to  bed  in  a  darkened  room,  and  drop  into  the  eye 
a  solution  of  atropia,  four  grains  to  the  ounce,  followed  by  the  appli- 
cation of  cold  cloths  for  at  least  twenty-four  hours.  Later  a  bandage 
is  to  be  applied  and  the  patient  permitted  to  go  about. 

Any  subsequent  disturbance  calls  for  an  examination  by  an  oculist. 

(b)  Deep,  penetrating,  non-infected  wounds  of  the  globe  are  serious 
in  various  degrees,  depending  upon  the  region  involved,  though  they 
usually  heal  kindly.  Injuries  of  the  sclero-corneal  junction  or  ciliary 
body  often  lead  to  sympathetic  ophthalmia,  and  may  require  early 
or  late  enucleation. 

The  treatment  is  simple.  Prevent  infection  by  the  free  use  of  boric 
acid  solution,  followed  by  one  or  two  drops  of  the  atropine  solution, 
and  the  application  of  a  sterile  eye  dressing.     Rest  in  bed  is  indicated. 

Every  wound  of  the  sclera  of  any  moment  requires  suture,  which  is 
the  best  means  of  preventing  infection.  Infected  wounds  require 
an  immediate  and  circumspect  treatment. 

If  the  vitreous  is  involved,  the  eye  is  almost  certain  to  be  lost.  The 
prognosis  is  somewhat  better  if  the  cornea  alone  is  involved. 


WOUNDS    OF   THE    EXTREMITIES.  87 

The  eye  is  to  be  irrigated  with  warm,  sterile,  saturated  solution 
of  boric  arid,  followed  by  a  few  drops  of  the  atropine  solution,  the 
whole  to  be  repeated  every  two  or  three  hours,  until  the  redness  passes 
away.  In  the  meantime,  heal  or  cold  is  to  be  applied,  depending  upon 
which  gives  the  most  comfort,  except  in  the  case  of  the  cornea,  where 
heat  is  always  the  better  application. 

Morrison  recommends  as  the  best  eye  pad,  several  thicknesses  of 
sterile  gauze  held  in  place  by  a  single  thickness  of  bandage  or  a  strip 
of  adhesive  plaster  so  that  it  can  be  frquently  changed. 

To  sum  up,  then,  the  chief  ends  of  the  emergency  treatment  are 
two;  asepsis  and  conservation.  Only  very  rarely  will  the  question  of 
enucleation  present  itself  as  an  emergency.  The  careful  examination 
which  should  be  given  every  injured  eye,  should  be  preceded  by  a 
regulated  asepsis.  Prepare  the  hands;  prepare  the  orbital  and  palpe 
bral  regions  by  patient  washing  with  warm  sterile  water  and  soap, 
avoiding  all  pressure  or  rough  handling  which  may  aggravate  the 
ocular  lesions.  Cleanse  the  conjunctiva  of  the  grosser  dirt  and  im- 
mediately instill  a  few  drops  of  cocaine  solution.  In  a  few  minutes 
the  cleansing  of  the  globe  and  palpebral  may  be  completed  without 
pain,  and  a  careful  examination  made  and  the  treatment  instituted. 

If  suture  is  required,  use  a  small  curved  needle  held  with  a  forceps, 
employing  catgut  No.  00,  and  above  all,  a  minute  care  and  a  light 
hand. 

The  suture  should  not  pass  through  the  entire  thickness  of  the 
sclerotic  coat,  but  only  through  the  conjunctiva  or  the  most  superficial 
layers  of  the  sclera.  The  reunion  will  usually  be  perfect  if  the  sutures 
are  carefully  passed  and  slowly  tied.     (See,  also,  Foreign  Bodies.) 

WOUNDS  OF  THE  EXTREMITIES. 

Wounds  of  the  extremities  call  for  varied  application  of  all  the 
principles  of  treatment  of  wounds,  hemostasis,  antisepsis,  and  suturing. 

Only  thorough  familiarity  with  these  principles  will  give  one  address 
in  the  management  of  the  individual  case,  for  no  two  injuries  are 
exactly  alike.  It  will  be  advantageous  to  exemplify  these  principles 
with  special  reference  to  wounds  of  the  extremities. 


WOUNDS    OF   SPECIAL    REGIONS. 


AN  INCISED  WOUND  OF  THE  WRIST. 

In  such  a  case,  there  may  be  copious  bleeding;  a  large  artery,  the 
radial,  for  example,  may  be  involved.  Begin  the  treatment  by  elevat- 
ing the  arm  and  applying  circular  constric- 
tion to  secure  a  temporary  hemostasis  (Fig. 
63).  Next  cleanse  the  field  and  then  the 
wound  itself. 

Separating  the  lips  of  the  wound,  locate 
and  clamp  the  superficial  veins  (Fig.  64). 
It  is  not  likely  that  they  will  need  to  be 
ligated.  Search  for  the  artery;  both  ends 
must  be  tied  and  it  is  not  necessary  to 
separate  the  companion  vein.  The  two  are 
ligated  together  (Fig.  65). 

Release  the  constrictor.  The  oozing  is 
nearly  always  very  free  at  first,  due  to 
temporary  vaso-motor  paralysis,  but  it  is 
not  at  all  serious. 

Apply  compresses  for  a  few  minutes, 
thus  arresting  the  capillary  bleeding,  and 
if  a  new  point  spurts,  apply  a  ligature. 
Inspect  the  wound  carefully  and  if  a  tendon 
or  nerve  is  divided,  it  must  be  immediately 
sutured  (wound  at  bend  of  elbow.    Fig.  66). 


A  STAB  WOUND  OF  THE  THIGH. 

(Fig.  67.) 

The  femoral  has  been  wounded  and  the 
hemorrhage  is  furious.  Direct  an  assistant 
to  make  firm  digital  pressure  over  the  artery 
as  it  crosses  the  pubes,  nor  must  this  pres- 

Piff.  63.-incised  wound  of  wrist.  sure  be  relaxed.     If  his  fingers  tire,  a  second 

Tourniquet  applied.    (Veau.)     assistant  may  press  upon  the  fingers  of  the 

first  (Fig.  68).     Enlarge  the  wound  freely  in  both  directions  in  the 

course  of  the  artery.     Sponge  out  the  clots;  identify  the  aponeurosis 


A    STAIS    win  \i>    or   Tin;   TIIICII 


89 


and  divide  il  in  order  to  expose   the  artery;   isolate   the  artery  by  (  .ire- 
ful  blunl   dissection   and    find    the    two   ends,    which    is   often    diffil  nil 

when  the  artery  is  completely  divided  (Fig.  69). 

When  both  ends  are  found,  ligate  with  catgut  No.  3,  or  silk.  No.  2, 
fFig.  70).  Tic  the  injured  vein  next  both  above  and  below.  It  is  to  be 
tied  separately  from  the  artery  (Fig.  71).     The  possibility  of  including 

a  nerve  in  the  ligature  must  always  be  borne  in  mind  and  no  ligature 
is  to  be  finally  tied  until  certain  that  no  nerve  is  to  be  thus  compressed, 


Pn 


64. — Incised    wound    of    wrist.      Bleed- 
ing vessels  clamped.      (Veau.) 


Fig.  65. — Incised  wound  of  wrist. 
Vessels  ligated.      (Venn.) 


to  become  later  a  source  of  pain.      Remove  the  pressure  and  catch  any 
more    vessels    that    might    bleed;    employ    free    drainage    and    suture 

incompletely. 

Apply  >lerile  gauze  dressing,  absorbent  cotton,  and  a  bandage, 
making  moderate  pressure,  and  maintain  the  limb  in  moderate  ele- 
vation.     Renew    the  dressings  on   the   third   day,   and    if   there   are   no 

complications,  remove  the  drainage.     Remove  the  sutures  about  the 

eighth  day. 

Certain   complications   may   arise.      If  the  ligatures   were   imperfect, 


9° 


WOUNDS   OF   SPECIAL   REGIONS. 


hemorrhage  may  ensue;  the  operation  has  to  be  repeated  and  the  vessels 
tied  again.  If  infection  occurs,  if  the  temperature  reaches  ioi°  F., 
open  up  the  wound  and  establish  better  drainage,  which  is  the  best 
means  of  preventing  secondary  hemorrhage.  Gangrene  sometimes 
follows  the  ligation  of  a  main  artery.  Watch  the  temperature  of  the 
extremity  and  look  for  pulsation  in  the  arteries  below  the  ligature. 
If  pulsation  is  present,  be  in  no  haste  to  amputate.  If  gangrene  does 
not  develop  before  the  fourth  day,  it  is  not  likely  to  do  so. 


Fig.  66. — Wound  at  bend  of  elbow,    i,  Basilic  vein;  2,  median  cephalic  vein;  3,  biceps 
tendon;  4,  bicipital  fascia;  5,  brachial  artery;  6,  brachial  vein;  7,  median  nerve. 

Crushing  and  lacerating  wounds  of  the  extremities,  as  Lejars 
says,  give  rise  to  the  most  perplexing  problems  of  emergency  surgery. 
The  questions  present  themselves  in  this  form:  To  amputate,  or  not 
to  amputate?  and  if  the  latter,  when,  at  what  point,  and  by  what 
method  ? 

In  order  not  to  be  vacillating  in  his  treatment,  every  doctor  must 
have  his  principle  of  action  settled  once  for  all. 

Lejars  states  his  guiding  principle  and  rule  of  action  in  this  manner: 


CRUSHING   INJURIES   TO   Tin:   EXTREMITIES. 


91 


Above  all,  save  the  patient's  life;  save  the  limb  wherever  possible,  or 

at  least  limit  the  mutilation  to  the  minimum. 

Clinically,  he  places  these  injuries  in  two  groups:  (a)  those  in  which 
a  segment  of  the  limb  is  crushed  or  otherwise  injured  without  periph- 


Fig.  67 


thigh. 


Fie.  68. — Stab  wound  of  thigh.  Com- 
pressing artery  while  the  wound  is  en- 
larged.     (IVjk.) 


eral  involvement,  and  (b)  injuries  extending  from  the  hand  or  foot 
upward. 

(a)  Suppose  a  case:     An  arm  has  been  run  over  by  the  wheels 
heavy  vehicle.     The  member  is  flail-like,  although  the  skin  is  not 
broken,  and  there  are  no  particular  points  of  bleeding.     Palpation 


92 


WOUNDS    OF   SPECIAL   REGIONS. 


Fig.  69. — Exposing  the  wounded  vessel.     (Veau.) 


Fig.   70. — Isolating  and  ligating  the  artery.        Fig.  71. — Ligating  the  vein.     (Veau  ) 
(Veau.) 


CRUSHING   INJURIES   To   Till.    EXTREMITIES.  93 

through  the  skin  over  the  injured  segment  shows  that  the  deeper 

structures  have  been  reduced  to  a  pulp,  both  muscle  and  bone. 

Still,  below  the  wound,  the  radial  and  ulnar  arteries  are  found  to 
pulsate.     This  is  an  absolute   indication  against  amputation.     The 
immediate  treatment  must  be  limited  to  a  careful  disinfection  of  the 
member,  the  repair  of  any  superficial  wounds,  a  complete  envelop 
ment  in  absorbent  cotton,  and  immobilization. 

The  immobilization  is  an  essential  feature,  for  by  that  means  any. 
bending  and  stretching  of  the  vessels  is  prevented  and  repair  favored. 
If  die  skin  is  broken  and  the  bone  crushed  or  shattered  and  exposed, 
the  injury  is  a  compound  fracture  and  is  to  be  dealt  with  accordingly, 
but  the  prognosis  always  depends  upon  the  blood  supply. 

If  in  the  case  instanced,  there  is  absolutely  no  pulsation  in  the  prin- 
cipal arteries,  it  is  certain  that  a  part  of  the  limb  is  lost;  yet  an  im- 
mediate operation  is  not  indicated.  There  are  two  reasons  for  this; 
first,  that  the  shock  may  subside,  and  second,  that  too  much  of  the 
limb  may  not  be  sacrificed,  which  latter  an  immediate  amputation 
nearly  always  means. 

Proceed  to  a  most  rigorous  disinfection  and  await  a  line  of  demar- 
cation. This  is  the  rule  to  which  there  are  two  exceptions,  one 
apparent,  and  the  other  actual. 

If  the  injury  is  a  crushing  one  and  the  member  hangs  by  shreds  of 
tissue,  there  is  absolutely  no  use  in  waiting;  but  the  completion  of 
the  ablation  does  not  require  an  amputation,  it  is  merely  what  Lejars 
terms  a  "regularization." 

Trim  up  the  tissues  sparingly  and  remove  enough  bone  that  a 
proper  stump  may  be  formed,  and  then  patiently  cleanse  the  wound 
with  hot  sterile  water  or  normal  salt  solution,  followed  by  alcohol. 
Suture  completely  and  then  cover  the  wound  with  sterile  gauze  sat- 
urated with  alcohol;  finally  cover  all  with  a  thick  layer  of  cotton  firmly 
bandaged. 

Almost  always  by  this  means  a  better  functional  result  may  be 
obtained  than  by  a  formal  amputation  quite  above.-  the  site  of 
injury. 

There  is  an  actual  exception  to  the  rule  of  conservatism.  The  case 
is  seen  late  and  there  are  already  signs  of  approaching  infection.     It  is 


94  WOUNDS   OF   SPECIAL   REGIONS. 

not  safe  to  delay  and  risk  the  sepsis  which  menaces.  It  is  better,  under 
such  circumstances,  to  proceed  to  immediate  amputation. 

(b)  Crush  or  laceration  extending  from  the  hand  or  foot  upward. 

Suppose  you  are  called  to  treat  the  foot  and  part  of  the  leg,  or  a  hand 
and  part  of  the  forearm,  which  have  been  crushed  and  lacerated. 
The  member  appears  injured  beyond  remedy.  Will  you  immediately 
proceed  to  amputate  ?     By  no  means — or  at  least,  not  as  a  rule. 

If  the  case  is  seen  immediately,  the  first  effort  should  be  devoted  to 
combating  shock  and  infection. 

It  is  not  altogether  on  account  of  shock  that  one  waits;  there  are 
other  even  more  important  reasons.  The  first  is  that  you  may  not 
amputate  high  enough;  the  second,  that  you  may  amputate  too  high. 
One  cannot  always  determine  from  the  first  how  high  the  devitalized 
tissues  extend.  There  may  be  vascular  injuries  or  muscular  lacera- 
tions which  are  concealed  by  a  sound  integument,  and  which  may 
later  be  the  source  of  gangrene.  Out  of  this  grows  the  necessity  of  a 
secondary  amputation,  which  is  always  a  matter  of  chagrin  to  the 
surgeon  and  an  element  of  danger  to  the  patient. 

On  the  other  hand,  tissues  which  appear  devitalized  may  finally 
survive  and  thus  preserve  a  function  which  might  otherwise  have  been 
sacrificed. 

It  is  true  that  a  few  inches  more  or  less  of  the  arm  or  leg,  for  instance, 
may  make  no  great  difference  in  the  usefulness  of  the  stump;  it  is 
quite  otherwise  when  the  question  is  that  of  amputating  immediately 
above  or  below  the  elbow  or  the  knee,  or  through  them.  Nor  do  rules 
of  conservation  apply  with  equal  force  to  the  foot  and  the  hand. 

As  Simons,  of  Charleston,  S.  C,  says  (International  Journal  of 
Surgery,  August,  1906),  injuries  of  similar  degree  affecting  the  upper 
or  lower  extremity  demand  different  treatment,  because  of  the  much 
greater  freedom  of  collateral  circulation  in  the  former  rendering  gan- 
grene less  probable. 

Where  conservatism  or  excision  would  be  proper  in  the  upper 
extremity,  amputation  would  be  called  for  in  the  lower  limb. 

Extensive  comminution  and  loss  of  bone  of  the  foot  may  demand 
amputation  because,  if  saved,  the  member  may  be  useless  as  a  means 
of  locomotion,  and  should  give  way  to  a  vastly  more  useful  artificial  limb. 


TK1  A  I  Ml   \  I     01      IN.II    RU  S    TO    THI.    HAM'. 


95 


( treat  laceration  of  the  soft  parts  of  tin-  foot,  with  free  i  omminution 
of  bone  and  injury  to  vessels,  always  demands  amputation;  for  the 

destruction  of  the  skin  of  the  heel  and  sole  will  result  in  a  cicatrix  which 
can  never  bear  the  weight  of  the  body  and  may  never  be  anything  but  a 
source  of  suffering  and  discomfort  to  its  possessor. 

But,  aside  from  these  exceptions  and  others  to  be  noted,  the  rule 
holds  in  this  class  of  injuries,  to  avoid  amputation  and  devote  one's 
skill  to  preventing  infection.  The  prevention  of  infection  is  the  sine 
qua  turn;  if  the  efforts  in  this  direction  are  going  to  be  half-hearted,  it  is 
better  to  amputate  at  once. 

Immediate  amputation,  again,  is  indicated  if  the  wound  is  seen  some 
hours  after  the  accident,  and  is 
found  soiled  and  dirty  and  mani- 
festly infected. 

Under  these  conditions,  con- 
servatism is  not  the  best  course, 
for  there  are  too  many  chances 
that  the  attempt  at  disinfection 
will  fail;  that,  in  spite  of  the  best 
efforts,  sepsis  will  arise.  Or,  if 
there  are  already  present  the 
symptoms  of  dangerous  sepsis, 
it  is  no  longer  a  question  of 
saving  a  limb,  but  of  saving  a 
life,  and  it  will  be  the  part  of  conservatism  to  amputate  well  above 
the  suspected  level. 

With  regard  to  the  conservative  treatment  of  these  severe  crushing 
and  lacerated  injuries  of  the  hands  and  feet  which  most  surgeons  would 
be  prone  to  amputate,  Reclus,  of  Paris,  has  emphasized  the  value  of 
thorough  and  patient  disinfection  of  the  skin  and  then  of  the  wound, 
together  with  a  trimming  away  of  the  devitalized  fragments  of  skin  and 
bone.  He  then  "embalms"  the  member  in  gauze  saturated  with  an 
antiseptic  pomade,  crowded  into  all  the  recesses  of  the  wound,  and  the 
whole  covered  by  a  thick  dressing  of  absorbent  cotton  and  bandaged. 
This  dressing  is  left  undisturbed  until  repair  is  complete,  unless  the 
temperature  should  rise  or  a  disagreeable  odor  develop. 


Fig.  72. — Ball  of  gauze  for  support  of  fingers. 
(Marsee.) 


96 


WOUNDS    OF    SPECIAL   REGIONS. 


Fig.  73. 


-Thumb  pinched  off  leaving  square- 
ended  stump.     (Marsee.) 


Joseph  Marsee  (Ind.  Med.  Jour.,  April,  1896)  has  made  some 
useful  observations  with  respect  to  the  treatment  of  common  injuries 
of  the  hand,  which  are  well  worth  repeating  and  which,  as  he  points 

out,  appeal  especially  to  the 
young  man  just  beginning  his 
life's  work,  for  such  will  prob- 
ably constitute  the  bulk  of  his 
surgical  practice  for  some  years. 
There  is  a  natural  tendency,  in 
the  popular  mind,  to  measure  an 
injury  by  the  size  of  the  member 
involved,  and  the  man  who 
would  insist  upon  the  best  advice 
in  other  cases,  will  fly  to  the 
nearest  doctor's  sign  when  "only 
a  finger"  is  involved.  But 
Marsee  concludes,  from  his  own 
experience,  that  the  young  practitioner  is  an  accomplice  in  spoiling  a 
good  many  hands  before  he  learns  to  do  them  justice.  On  the  other  side, 
it  is  not  too  much  to  say  that  the  best 
human  skill  is  none  too  good  when  em- 
ployed in  repairing  injuries  of  the  most 
mechanically  perfect  human  member. 
The  majority  of  these  injuries  occur 
in  workers  with  machinery;  the  hand, 
therefore,  is  always  soiled  and  gen- 
erally greasy.  This  grease  must  first 
be  removed.  Nothing  is  better  for 
this  purpose  than  ordinary  gasoline  or 
benzine,  which  may  be  poured  into 
the  hand  directly  from  the  bottle. 
The  fluid  will  find  its  way  into  the 
smallest  recesses  of  the  wound,  washing 
out  the  grime  and  preparing  the  way 

for  the  other  antiseptics.     The  benzine  is  poured  on  until  all  the  grease 
is  removed,  and  the  disinfection  is  completed  in  the  ordinary  way. 


Fig. 


Amputation    com- 
(Marsee.) 


I -K' I  VI  Ml  NT   OF    IN  M  Kll  S   TO   MM     HAND. 


97 


1 

"    1 

- 

Fig.  75. — Amputation  of  index  finger.     Head 
metacarpal  retained.     (Marsee.) 


Even  slight  wounds  of  the  fingers  and  palms  should  be  treated  by 
enforced  rest  by  a  splint  or  plaster-of-Paris  dressing,  complete  enough 
to  preclude  all  motion.  This  prophylaxis  is  not  regarded  as  unneces- 
sary by  those  who  have  seen  the 
most  marked  deformities,  the 
gravest  constitutional  disturb- 
ances, and  even  death,  result 
from  trilling  wounds  of  the 
hand.  Enforced  rest  which 
leaves  nothing  to  chance,  to 
caprice,  or  the  patient's  med- 
dling is  alone  reliable.  Under 
such  treatment,  the  rapidity  with 
which  alarming  symptoms  some- 
times disappear  is  truly  remark- 
able.      If    a    plaster    casing   is 

used,   it  should  extend  from  several  inches  above  the  wrist  to  the  ex- 
treme tips  of  the  fingers,  the  thumb  being  also  enclosed  if  necessary. 
When  finger  wounds  are  extensive  and  parallel  with  the  long  axis, 

it  is  better  not  to  suture  them  at 
once,  for  the  swelling  will  gen- 
erally    be     extensive    and    the 
stitches  will  cut  out.     After  the 
inflammation  has  subsided,  the 
edges  may  be  freshened  and  ap- 
proximated.    Nor  does  Marsee 
advise    immediate    splinting     in 
the  case  of  crushing  injuries  of 
the    fingers,    for    fear   that    the 
circulation    may    be    interfered 
with.    However,  that  the  crushed 
member  may  not  be  wholly  un- 
supported, a  soft   ball   covered 
with  cotton  and  wrapped   with  gauze  is  applied  to  the  palm  so  that 
the  fingers  may  be  spread  out  over  it  comfortably  (Fig.  72),  and  the 
whole  dressed  with  absorbent  cotton  and  lightly  bandaged.     The  ball, 
7 


Fig.  76. — Amputation  of  index  finger.  Head 
of  metacarpal  removed  making  much  more 
sightly  hand.      (Marsee.) 


98 


WOUNDS    OF    SPECIAL    REGIONS. 


Fig.    77. — Loss  of  ring  finger. 
Dorsal  view.      (Marsee.) 


as  Marsee  indicates,  though  unsightly 
and  bulky,  has  no  other  fault;  it  is  light, 
absorbent  and  wonderfully  comfortable, 
and  needs  only  a  trial  to  be  appreciated 
and  adopted.  It  should  be  used  until 
the  tissues  are  beyond  danger,  though  it 
takes  several  days,  a  week  or  a  month 
No  time  is  lost,  for  healing  cannot  begin 
until  vitality  is  restored,  and  this  will 
always  be  slow  in  such  cases,  a  fact  which 
should  be  brought  thoroughly  to  the 
patient's  knowledge  from  the  beginning, 
that  the  doctor  may  not  be  blamed  for 
the  tardy  convalescence. 

With  regard  to  methods  of  amputating 

fingers,   opinion  is  divided   on  the  question  as  to  which  is  the  more 

desirable,  a  palmar  flap,  or  a  slightly 

longer  finger  with  a  dorsal  flap  cover- 
ing the  stump. 

There    can   be   no  doubt  that  a 

palmar  flap  is  desirable,  and  Marsee 

believes  in  securing  it,  even  at  the 

expense   of   sacrificing  more  of  the 

finger.       If     more     than     half    the 

phalanx  is  gone,  it  is  always  better, 

in  his  opinion,  to   amputate  at  the 

joint    line  and  thus  avoid  a  flexed 

stump. 

If  a  portion  of  the  distal  phalanx 

remains,    the    nail    should    be   re- 
moved   and     the    matrix    dissected 

before  the  flap  is  adjusted,  or  some 

deformed     fragment    of    nail    may 

be  left   to   vex    the  patient.      It    is 

,      . ,  .  r  ,  Fig.  78. — The  loss  of  the  ring  finger 

better,   in   removing  a   finger    at    a  is  hardly  noticed  when  distal  half  of 

.    .     ,       ,  ,         n-     .1         •.         it  the     metacarpal     bone     is     excised, 

joint,    to    cut   off   the   knobby  pro-    {Marsee.) 


■ 


ink  Kirs   th    mi'.  thorax. 


99 


iections  of  the  condyles  on  the  palmar  surface  and  to  scrape  off  the 
exposed    cartilage. 

If  the  finger  is  pinched  off  squarely,  one  must  always  insist  in  re- 
moving enough  of  the  bone  to  give  a  good  flap,  for  if  the  patient  has 
his  way  and  the  stump  heals  by  granulation,  the  result  will  be  unsatis- 
factory and  the  doctor,  event- 
ually, will  have  to  bear  the 
blame  (Figs.  73,  74). 

If  the  whole  finger  requires 
amputation,  the  head  of  the 
metacarpal  bone  will  require 
special  attention  and  the  pro- 
cedure will  be  different  with 
the  different  fingers. 

Remove  the  heads  by 
oblique  section  in  the  case  of 
the  index  and  little  fingers 
(Figs.  75,  76).  Generally  re- 
move the  head  of  the  meta- 
carpus in  the  case  of  the  ring 
finger,  cutting  back  far 
enough  to  let  the  heads  of  the 
adjacent  bones  fall  together 
(Figs.  77,  78). 

Do  not  remove  the  metacarpal  head  of  the  middle  finger  unless  the 
appearance  of  the  hand  is  the  chief  consideration.  Marsee  states 
as  the  reason  for  this,  that  it  tends  to  let  the  other  fingers  fall  away  from 
the  thumb  and  thus  interferes  with  ready  apposition  (Fig.  79). 


Fig.  79. — The  stump  of  the  index  finger 
falls  away  from  thumb  when  head  of  middle 
metacarpal  has  been  removed.     (Marsee.) 


INJURIES  TO  THE  TRUNK. 

INJURIES   TO   THE   THORAX. 

Certain  elementary  notions  must  be  clearly  comprehended  and  kept 
in  mind  in  order  to  make  a  definite  diagnosis  of  these  injuries.  These 
notions  relate  to  the  anatomy,  pathology,  and  symptomatology  of  the 
thorax.     With  respect  to  the  anatomy,  one  must  keep  in  mind  the 


IOO  WOUNDS    OF    SPECIAL    REGIONS. 

location  of  the  principal  vessels  of  the  chest  wall  and  mediastinum; 
the  relations  of  the  viscera  to  the  ribs;  and  the  normal  areas  of  reson- 
ance and  dullness.  In  addition,  it  is  necessary  to  recall  the  signs  and 
significance  of  the  principal  primary  complications  possible  in  any 
form  of  serious  violence  to  the  thorax,  viz.:  hemoptysis,  hemothorax, 
pneumothorax,  emphysema,  and  hemo-pericardium. 

Hemoptysis,  following  an  injury  to  the  thorax,  whatever  its  nature, 
is  significant  of  one  thing- — that  the  lung  has  been  involved.  The  de- 
gree of  injury  may  be  in  a  manner  estimated  by  the  amount  of  blood 
expectorated.  In  the  dangerous  cases,  the  blood  pours  from  the 
wounded  lung  tissue  into  the  bronchus  and  gushes  from  the  mouth. 
In  other  cases,  there  is  only  a  slight  spitting  of  blood,  leading  to  the 
belief  that  the  lung  has  not  been  seriously  torn.  It  might  be  mistaken 
for  a  hematemesis,  but  the  presence  of  rales  in  the  bronchus  of  the 
affected  side  (or  of  both)  and  the  light  color  of  the  blood  and  its  admix- 
ture with  air,  point  to  the  character. of  the  hemorrhage. 

Hemothorax,  an  accumulation  of  blood  in  the  pleura,  is  nearly 
always  the  result  of  injury  to  the  lung;  although,  of  course,  the  internal 
mammary  artery  or  the  intercostals  may  occasionally  be  the  source  of 
the  extravasation.  Gravity  determines  where  the  blood  will  accumu- 
late and  therefore  the  patient's  position  will  modify  the  physical  signs. 

The  symptoms  and  signs  are  both  modified  by  the  quantity  of 
blood  and  the  rapidity  with  which  it  is  poured  into  the  pleural  cavity. 
In  the  slighter  forms,  there  is  scarcely  any  disturbance  of  breathing 
and  only  slight  dullness  over  the  base  of  the  lung. 

In  the  graver  forms,  the  lung  is  collapsed  and  crowded  toward  the 
hilum,  so  that  there  are  symptoms  of  asphyxia  added  to  those  of  in- 
ternal hemorrhage.  The  face  is  pale,  the  skin  moist  and  cold,  the 
patient  is  impelled  to  sit  up  and  gasps  for  breath,  the  pulse  is  rapid 
and  thready,  and  the  patient  may  thus  go  on  to  death.  Inspection 
reveals  a  slightly  bulging  chest  wall;  percussion,  a  complete  dullness; 
and  auscultation,  an  absence  of  fremitus  and  of  the  vesicular  murmur. 

Often  there  is  an  immediate  rise  of  temperature,  due  to  absorption, 
and  which  is  to  be  distinguished  from  the  temperature  of  infection  by 
its  earlier  appearance. 

No  attempt  to  evacuate  the  extravasated  blood  is  to  be  made  in  the 


IN JXTRH  S    TO    THE    THORAX.  IOI 

moderately  severe  cases;  in  others,  of  more  urgency,  an  aspiration 
may  give  some  temporary  relief,  tiding  the  patient  over  a  critical  point. 
Finally,  in  rart-  rases,  the  magnitude  <>l"  the  hemothorax  will  be  su<  h  as 
to  demand  an  immediate  intervention,  with  the  purpose  in  view  of 
exposing  the  lung  and  repairing  the  wound  in  its  substance.  Subse- 
quently, even  it'  the  case  is  mild,  infection  may  occur  and  is  to  be  treated 
as  any  other  empyema. 

Pneumothorax. — Air  may  enter  the  pleural  cavity  from  without 
through  an  opening  in  the  chest  wall,  or  from  within  through  a  rupture 
in  the  lung  tissue.  In  the  first  case  it  enters  during  inspiration,  and 
in  the  second,  during  expiration. 

The  physical  signs  and  symptoms  grow  out  of  the  pressure  within 
the  pleural  cavity  and  the  consequent  collapse  of  the  lung.  The 
chest  wall  on  the  injured  side  is  distended,  the  intercostal  spaces 
bulged  out,  the  viscera  are  displaced,  the  ribs  motionless,  the  vesic- 
ular murmur  absent.  If  a  coin  laid  on  the  front  of  the  chest  is  tapped 
with  another  coin,  the  sound  will  be  heard  at  the  back.  The  symp- 
toms are  principally  those  of  dyspnea. 

If  there  are  no  complications,  the  air  is  gradually  absorbed  and  the 
function  of  the  lung  restored. 

In  extreme  cases,  puncture  will  relieve  the  intrapleural  pressure; 
and  in  the  case  of  a  valvular  wound  in  the  chest  wall,  which  permitted 
entrance  of  the  air  but  not  its  exit,  enlargement  of  the  wound  is 
indicated. 

If  air  and  blood  accumulate  simultaneously — if  a  hemo- pneumo- 
thorax exists — the  physical  signs  will  be  altered,  but  not  the  symptoms. 

Emphysema. — The  subcutaneous  cellular  tissue  may  become  charged 
with  air  and  practically  the  whole  body  be  involved.  It  is  nearly 
always  due  in  the  marked  cases  to  puncture  of  the  lung  by  a  broken 
rib.  The  air  esc  aping  from  the  lung  is  prevented,  by  the  close  contact 
of  the  pleural  surfaces,  from  entering  the  pleural  cavity,  and  is  forced 
into  the  loose  tissues  of  the  ruptured  chest  wall. 

In  other  rarer  cases  the  inner  aspect  of  the  lung  is  wounded,  and 
the  air  escapes  into  the  tissue-  of  the  mediastinum,  and  follows  them 

up  into  the  neck. 

In  ordinary  cases  no  treatment  is  indicated  and  the  air  is  soon  ab- 


102  WOUNDS   OF   SPECIAL   REGIONS. 

sorbed.  However,  in  the  severer  forms,  the  symptoms  of  asphyxia 
and  cyanosis  may  supervene  and  then  free  incision  over  the  infiltrated 
zone  may  be  required. 

Hernia  of  the  lung  is  a  rare  complication,  and  may  be  immediate  or 
secondary.  In  the  first  case,  the  pulmonary  tissue  is  forced  through 
the  breach  in  the  chest  wall  by  violent  expiratory  effort.  In  some 
cases  where  the  skin  is  not  broken,  the  hernia  may  be  felt  as  a  crepitant 
tumor  beneath  the  skin. 

In  the  secondary  cases,  it  forms  more  slowly,  and  is  often  due  to  the 
weakening  of  the  thoracic  wall  by  inflammatory  processes. 

Hemo-pericardium. — Blood  in  the  pericardial  sac  follows  injury 
to  the  pericardium.  It  develops  more  rapidly  and,  of  course,  the  out- 
look is  much  more  grave  if  the  heart  is  also  wounded. 

The  symptoms  are  those  of  syncope  induced  by  the  compression 
of  the  heart  by  the  accumulated  fluid;  the  signs  are  those  of  increased 
cardiac  dullness.  The  apex  beat  is  lost,  the  heart  sounds  muffled,  the 
precordium  bulged.  It  is  upon  the  signs  that  one  must  depend  for 
^the  diagnosis,  for  the  symptoms  are  often  complicated  by  those  of 
shock  and  by  those  which  originate  in  other  injuries  in  the  thoracic 
region. 

To  repeat,  then,  when  you  reach  the  patient  suffering  from  some 
form  of  chest  injury,  you  will  observe  the  character  of  his  respiration 
and  his  pulse;  whether  his  condition  is  immediately  serious  or  not  is 
to  be  determined  at  once  by  that  means.  If  the  circumstances  permit, 
you  will  proceed  to  a  systematic  examination.  Learn  from  the  suf- 
ferer the  location  of  his  pain  and  the  character  of  his  chief  distress. 
Note  the  appearance  of  the  sputum,  if  there  is  cough.  Inspect  the 
chest  wall  for  change  in  outline  and  mobility  and  location  of  apex 
beat.  Determine  by  percussion  the  limits  of  the  lung  resonance  and 
heart  dullness;  and  by  auscultation,  the  presence  or  absence  of  the 
vesicular  murmur  or  of  rales. 

The  case  may  be  so  grave  that  exact  diagnosis  is  unnecessary;  or, 
again,  it  may  require  the  most  minute  examination  and  judicious 
weighing  of  the  symptoms  and  signs  to  make  a  correct  forecast  of  the 
eventualities,  and  to  formulate  a  treatment  which  will  leave  nothing 
to  regret. 


CONTUSIONS    OF    Till     MUST.  IO3 

CONTUSH  »\s  OF  THE  CHEST. 

Simple  contusions  of  the  thorax,  without  fracture  of  a  rib  or  the  ster- 
num (which  are  considered  elsewhere)  and  without  symptoms  point 

ing  to  internal  injury,  need  but  brief  consideration.  A  hematoma  i> 
likely  to  form.  The  pain  and  soreness  disappear  rapidly  in  the 
young,  but  are  extremely  persistent  in  the  aged  and  the  rheumatic. 
Strapping  and  massage  with  liniment  are  usually  sufficient. 

On  the  other  hand,  following  simple  contusion,  there  may  be  a  de- 
gree of  shock  out  of  all  proportion  to  the  trauma. 

A  man  of  thirty,  apparently  in  good  health,  received  a  slight  blow- 
oxer  the  chest  in  a  friendly  scuffle.  The  blow  was  slight,  and  yet  it 
seemed  to  touch  a  vital  spot  and  made  him  gasp  for  breath.  It 
was  with  difficulty  that  he  reached  home  and  for  two  weeks  he  seemed 
upon  the  verge  of  a  pneumonia.  A  month  later  he  was  still  unable 
to  work,  and  an  examination  at  this  time  revealed  grave  organic  lesions 
of  the  heart.  It  was  greatly  dilated  and  not  a  single  valve  seemed  to 
be  performing  its  function  fully.  In  spite  of  rest  and  treatment,  his 
condition  gradually  grewr  worse,  and  in  six  months  he  died  with  a 
general  anasarca.  We  must  consider  that  the  heart,  as  well  as  other 
organs,  is  liable  to  contusion  and  that  from  such  injuries  acute  endo- 
carditis may  result. 

In  graver  contusions,  such  as  crushing  injuries,  it  is  rupture  of  the 
lung  which  is  always  to  be  feared  and  which  is  usually  evidenced  by 
a  large  hemothorax.  It  must  always  be  remembered  that  such  an 
injury  may  occur  without  fracture  of  the  ribs  or  sternum. 

Lejars  cites  the  case  of  a  boy  eleven  years  of  age,  whose  chest  was 
run  over  by  a  wagon.  He  arose  immediately  after  the  accident,  but 
fell  again  unconscious,  with  blood  pouring  from  mouth  and  nostrils. 
This  hemorrhage  did  not  long  persist,  but  on  the  fourth  day  the  temper- 
ature rose  and  he  was  taken  to  the  hospital.  His  condition  was 
alarming,  the  pulse  weak  with  a  rate  of  104,  his  face  cyanosed  and  the 
dyspnea  intense;  his  heart  was  displaced  to  the  right,  and  on  the  left 
side  were  the  signs  of  marked  hemo-pneumothorax.  A  puncture 
removing  1S0  (1.  of  the  exudate  gave  but  temporary  relief.  The 
pulse  continued  to  grow    weaker  and  the  dyspnea  more  intense,  and 


104  WOUNDS    OF   SPECIAL    REGIONS. 

an  urgent  intervention  was  indicated.  The  pleura  was  opened  and 
the  lung  found  retracted  toward  the  hilum.  In  the  upper  lobe  a  tear 
was  found,  7  cm.  long,  and  running  upward,  and  backward  from  the 
cardiac  incisure.  The  wound  gaped  freely.  The  lung  was  drawn 
into  the  opening  in  the  chest  wall,  and  the  pulmonary  wound  repaired 
with  five  sutures  of  silk  which  included  considerable  tissue  to  prevent 
their  pulling  out.  The  coaptation  was  perfected  by  a  few  superficial 
sutures.  The  upper  lobe  was  sutured  to  the  parietes  and  a  tamponade 
with  gauze  completed  the  operation. 

The  outcome  was  unfortunate,  for  death  occurred  on  the  second 
day,  but  the  autopsy  found  the  lips  of  the  lung  wound  well  agglu- 
tinated.    There  was  no  costal  fracture. 

The  symptoms  of  rupture  of  the  lungs  are  the  same  whether  a  rib  be 
broken  or  not:  hemo-pneumothorax,  abundant  and  increasing;  a 
spreading  emphysema;  symptoms  of  grave  anemia;  to  all  these  may 
be  added  more  or  less  quickly,  the  symptoms  of  pleural  infection. 

The  treatment,  except  in  the  cases  of  extreme  urgency,  must  be  con- 
servative and  expectant.  Shock  must  be  combated,  the  patient  kept 
absolutely  quiet,  and  the  dyspnea  relieved  by  the  sitting  posture,  and, 
if  possible,  by  inhalations  of  oxygen. 

The  anemia  can  be  relieved  by  injections  of  small  quantities  of  nor- 
mal salt  solution  frequently  repeated. 

A  puncture  will  partly  empty  the  pleural  cavity,  affording  great 
relief;  and,  eventually,  the  remaining  exudate  will  be  absorbed. 

It  may  happen  that  after  two  or  three  days  the  symptoms  will 
improve. 

But  in  the  worst  cases,  where  the  dyspnea  is  progressive  and  menac- 
ing, and  the  heart  rapidly  growing  weaker,  the  responsibility  cannot  be 
shifted.  It  is  indicated  to  operate  at  once,  to  open  up  the  thorax  and 
repair  the  tear  in  the  lung,  to  do  an  urgent  thoracotomy  (see  page  423). 

OPEN  WOUNDS  OF  THE  THORAX. 

Non-penetrating  wounds  of  the  chest  wall  are  of  slight  significance 
and  are  to  be  treated  on  general  principles. 

Penetrating  wounds  of  the  thorax  derive  their  significance  from  the 


WOUNDS   OF    PL]  I  RA    AND    I  I  WG.  105 

particular  viscera  and  vessels  which  may  happen  to  he  involved.     On 

the  i  linical  basis,  then,  these  wounds  may  lie  divided  into  three  classes: 
.1.    Wounds  which  involve  the  pleura  or  Lung. 
B.   Wounds  which  involve  the  diaphragm. 
(.'.   Wounds  which  involve  the  pericardium  and  heart. 

A.       WOUNDS    OF    THE    PLEURA  AND   LUNG. 

In  whatever  manner  the  wound  may  be  inflicted,  there  are  three 
elements  of  danger:  hemorrhage,  asphyxia,  and  infection.  These  are 
the  factors  which  will  determine  the  line  of  treatment,  and  without 
some  urgent  indication  from  one  of  these  sources  the  treatment  must 
he  conservative.  There  are  many  things  which  stand  in  the  way  of 
radical  procedures  such  as  are  employed  in  the  case  of  ahdominal 
wounds.  In  the  first  place,  the  operative  technic  is  difficult;  there  is 
a  marked  disturbance  of  respiration  following  free  access  of  air  to 
the  pleural  cavity;  the  exact  location  of  the  lung  lesion  cannot  often 
be  determined;  and,  finally,  there  is  always,  as  Lejars  remarks,  so 
much  guesswork  in  the  prognosis,  that  we  are  constrained  to  give  the 
patient  the  benefit  of  the  doubt  and  leave  the  case  to  take  its  natural 
course. 

It  is  best  to  proceed  in  this  wise:  If  the  case  is  seen  from  the  first, 
supervise  the  transportation.  Too  much  importance  cannot  be  at- 
tached to  the  dangers  of  rough  handling.  As  has  been  said  elsewhere, 
the  nearest  shelter  is  the  best.  Cut  away  the  clothing,  scrub  the  skin 
adjacent  to  the  wound,  and  wash  out  the  wound  itself  with  alcohol  or 
sterile  salt  solution.  If,  on  opening  the  lips  of  the  wound,  a  bleeding 
point  is  seen,  catch  it  up  and  ligate. 

If  there  is  oozing  from  the  depths,  it  is  best  to  disregard  it  for  the 
present.  This  constitutes  the  primary  intervention  except  for  suture 
of  the  wound,  which  follows. 

Apply  a  dressing  of  sterile  gauze,  plain  or  soaked  in  collodion. 
Cover  this  with  a  layer  of  absorbent  cotton  and  apply  a  firm  bandage 
encircling  the  whole  chest.  Place  the  patient  on  his  back  with  the 
head  and  shoulders  slightly  elevated.  Absolutely  prohibit  conver- 
sation and  movement  of  any  kind;  and,  in  the  meantime,  keep  the 
patient  under  close  surveillance. 


106  WOUNDS   OF   SPECIAL   REGIONS. 

In  general  terms,  then,  the  treatment  of  any  ordinary  open  wound  of 
the  chest  involving  the  lung  and  pleura  is  to  be  summed  up  in  two 
words,  immediate  occlusion  and  immobilization. 

But  there  are  conditions  which  demand  immediate  intervention. 
These  are  acute  anemia  or  asphyxia,  which  may  follow  hemorrhage, 
external  or  internal;  and  hernia  of  the  lung. 

External  hemorrhage  may  follow  any  extensive  wound  of  the  chest 
wall,  welling  up  from  its  depths  or  flowing  by  spurts  during  expiration. 
If  there  is  no  hemoptysis,  it  may  be  inferred  that  the  lung  is  not 
wounded;  but,  in  any  event,  the  first  treatment  must  be  directed  to- 
ward the  intercostals  and  internal  mammary.  It  may  be  that  a  tempo- 
rary hemostasis  will  be  necessary,  and  the  tamponade  described  on 
page  49,  will  be  indicated. 

The  definite  hemostasis  requires  a  free  enlargement  of  the  wound. 
If  pressure  made  against  the  lower  border  of  the  rib  by  an  aseptic 
finger  introduced  through  the  enlarged  wound  causes  cessation  of 
hemorrhage,  it  is  certain  that  it  is  an  intercostal  artery  that  is  at  fault. 
It  may  be  difficult  to  clamp;  it  may  be  necessary  to  resect  a  rib,  or  to 
detach  the  periosteum,  which  will  carry  the  artery  with  it.  A  curved 
needle  threaded  with  catgut  is  then  carried  around  the  artery.  The 
ligature  is  tied  and  the  hemorrhage  thus  controlled.  The  internal 
mammary  may  require  ligation  above  and  below  the  wound. 

Internal  hemorrhage  is  in  every  way  more  serious,  for  to  the  anemia 
is  added  the  asphyxia  which  follows  the  compression  of  the  lung. 

The  patient  is  pale,  anxious,  with  cold  extremities,  weak  pulse,  and 
sighing  respiration;  the  chest  wall  bulges;  the  normal  resonance  and 
vesicular  murmur  are  altered;  in  short,  there  are  all  the  indications 
for  an  increasing  hemothorax  or  hemo-pneumothorax. 

But  even  in  the  presence  of  these  grave  symptoms,  it  is  by  no  means 
always  indicated  to  operate.  One  must  be  content  to  repair  the 
wound,  occlude  and  immobilize,  and  wait  awhile. 

But  when  the  wound  is-  followed  by  an  immediate  and  complete 
hemothorax,  or  when  the  symptoms  and  signs  point  to  a  rapidly  ap- 
proaching fatality,  one  must  .stand  by  with  folded  hands  and  see  the 
end  come,  or  operate;  for  there  is  nothing  else  of  any  use.  An  urgent 
thoracotomy  must  be  done. 


WOUNDS   OF   PLEURA  AND    LI  107 


Hernia  of  the  Umg  is  rare.  The  tumor  is  of  variable  size  and  is  at 
first  crepitant,  but  rapidly  darkens  and  becomes  hepatized. 

The  indications  for  treatment  depend  upon  the  time  which  has 
elapsed  and  upon  the  condition  of  the  tumor.  If  the  wound  is  recent 
and  the  lung  intact,  the  hernia  must  be  reduced.  Begin  by  a  careful 
disinfection  of  the  wound.  Cover  the  tumor  with  an  aseptic  com- 
press and  tuck  its  edges  under  the  whole  circumference  of  the  wound. 
A  steady  pressure  over  the  central  portion  of  the  tumor  will  expel  the 
air  little  by  little;  and,  by  reducing  its  volume,  favor  the  reduction  of 
the  tumor. 

The  compress  is  to  be  left  until  the  skin  wound  is  partially  sutured, 
since  by  that  means  one  may  prevent  the  sudden  pneumothorax  which 
sometimes  follows  reduction. 

If  the  lung  has  been  wounded,  it  must  be  repaired  by  suture,  or  by 
ligation  and  resection  before  being  reduced. 

If  some  time  has  elapsed,  it  is  as  unsafe  to  reduce  it  as  to  reduce  a 
doubtful  herniated  gut. 

Lejars  insists  upon  resection  with  the  thermocautery.  Around  the 
base  of  the  tumor  pass  a  ligature  threaded  on  a  blunt  needle.  By 
tying  the  ligature,  a  pedicle  is  formed  which  is  to  be  amputated  with 
the  thermocautery.  The  stump  is  carefully  disinfected  and  reduced, 
the  chest  wall  repaired,  and  drainage  instituted. 

Finally,  in  the  case  where  the  tumor  is  already  gangrenous  and  slough- 
ing, it  is  necessary  to  limit  the  treatment  to  antisepsis,  leaving  the 
slough  to  detach  itself,  and  happily  a  cure  may  follow  such  spontaneous 
amputation. 

Ax  tell  reports  a  case  of  open  wound  of  the  chest  which  illustrates 
what  the  doctor's  patience  and  nature's  efforts  may  accomplish  in 
conditions  apparently  most  desperate.  (American  Jour.  Surg., 
Feb.  1909.) 

A  shingle  sawyer  of  twenty-eight,  robust  and  muscular,  fell  against 
a  great  circular  saw  revolving  many  thousand  times  per  minute. 
Sections  of  the  second,  third,  fourth,  fifth  and  sixth  ribs  were  cut 
away,  these  segments  varying  in  length  from  one  inch  at  the  second  to 
three  inches  at  the  fourth  and  fifth  ribs.  The  costal  pleura  was  com 
pletely  destroyed  over  the  seat  of  the  greatest  injur}-.      The  lung  and 


108  WOUNDS    OF    SPECIAL    REGIONS. 

pericardium  were  exposed.  There  was  one  ^puncture  of  the  lung 
from  which  the  air  bubbled  and  emphysema  followed.  All  the  inter- 
costal arteries,  veins,  and  nerves  in  the  injured  area  were  severed. 
The  pectoralis  major  was  completely  separated  from  the  chest,  and  a 
part  of  the  pectoralis  minor.  The  wounded  man,  thrown  from  the 
saw,  fell  face  downward  into  a  dust  pile  and  the  whole  exposed  surface 
of  the  wound  was  filled  with  sawdust  and  grease. 

He  was  carried  to  the  hospital  and  attempt  made  to  repair  the 
damage.  "Over  450  spiculae  of  wood  fiber  were  picked  out  piece  by 
piece  from  the  chest  cavity  and  the  surface  of  the  lung.  Several  large 
lumps  of  greasy  dust  were  removed  from  the  depths  of  the  chest  cavity." 
All  the  ragged  edges  of  the  costal  pleura,  skin,  and  muscles  were 
trimmed  away.  The  jagged  and  uneven  ends  of  the  severed  ribs  were 
cut  off  smooth  in  order  to  bring  the  periosteum  over  them.  To  take 
the  place  of  the  costal  pleura  destroyed,  a  flap  was  stripped  off  the  pector- 
alis major  from  near  its  attachment  to  the  humerus;  left  attached  near 
the  free  end  of  the  divided  muscle,  it  was  turned  forward  toward  the 
sternum  and  sutured  to  its  margin,  to  the  intercostal  muscles,  and  the 
periosteum  of  the  stumps  of  the  ribs.  The  severed  muscles  were 
drawn  together  by  cable  sutures  and  the  skin  flap  drawn  into  place 
and  incompletely  sutured.  Ample  drainage  was  installed.  The  inter- 
vention consumed  several  hours,  something  like  180  sutures  and  liga- 
tures being  required.  The  emphysema  was  enormous  at  first,  ex- 
tending from  the  scalp  to  the  knees,  but  disappeared  after  48  hours. 
At  the  end  of  six  weeks  the  patient  had  practically  recovered  without 
adhesions  or  restriction  of  the  lung. 

B.       WOUNDS  AT   THE    BASE    OF   THE   THORAX. 

Wounds  at  the  base  of  the  thorax  require  a  separate  consideration, 
for  the  reason  that  both  the  thoracic  and  abdominal  cavities  may  be 
involved  through  wounds  of  the  diaphragm. 

It  must  be  remembered  that  the  d'aphragm  corresponds  to  the  level 
of  the  fifth  rib  in  the  right  nipple  line,  and  to  the  level  of  the  sixth  rib 
in  the  left. 

In  stab  or  gunshot  wounds,  the  lung  on  the  one  hand,  and  the 
stomach,  intestine,  spleen,  and  liver  on  the  other,  may  be  wounded  simul- 


WOUNDS    IT    mi     BAS1     01    im     THORAX.  109 

taneously;  so  that,  compared  with  the  thoracic  wounds  just  considered, 
those  at  the  base  arc  much  more  i  omplicated  with  respect  t<>  prognosis, 
diagnosis,  and  treatment. 

Ludlow,  of  Cleveland  (Annals  of  Surgery,  Jinn-,  [905),  reports  a  case 
which  illustrates  this  subject  and  exemplifies  the  treatment  in  general. 

The  patient  had  received  two  stab  wounds  in  the  left  side,  inflicted 
with  a  candy  maker's  knife  which  had  two  blades  set  in  a  heavy  handle. 
One  wound  entered  at  the  ninth  interspace  in  the  axillary  line,  and 
through  it  protruded  omentum.  The  blade  had  entered  the  chest 
wall  obliquely  and  the  skin  acted  as  a  valve;  but,  when  the  skin  was 
retracted,  the  air  rushed  in  and  out  of  the  pleural  cavity  with  each 
respiration.     The  hemorrhage  from  the  wound  was  slight. 

The  second  wound  was  situated  directly  below  the  first  in  the  elev- 
enth interspace.  Omentum  protruded  from  this  wound  also,  and  the 
bleeding  was  slow,  but  apparently  increasing. 

Operation.- — Ether  anesthesia;  a  careful  cleansing  of  the  field.  A 
digital  examination  revealed  the  fact  that  the  upper  wound,  traversing 
the  pleural  cavity  without  injury  to  the  lung,  had  perforated  the  dia- 
phragm. The  finger  passed  through  these  wounds,  met  the  finger  of 
the  other  hand  passed  through  the  lower  wound,  in  the  abdominal 
cavity. 

The  lower  wound  was  enlarged,  revealing  an  active  hemorrhage  from 
the  spleen.  The  cut  surface  of  the  spleen  was  pulled  into  the  wound 
and  a  spurting  artery  clamped.  The  splenic  wound  was  four  centi- 
meters in  length  and  extended  almost  through  the  substance  of  the 
organ. 

The  cut  surfaces  were  brought  into  apposition  by  mattress  sutures 
of  plain  catgut  No.  2,  on  a  curved  round  needle.  This  controlled  the 
hemorrhage.  Neither  by  palpation  or  inspection  could  any  wound  of 
the  Stomach  or  intestines  be  found.  The  diaphragm  was  then  repaired 
with  chromic  gut  No.  3.  The  operation  was  accomplished  without  the 
resection  of  a  rib.  A  small  cigarette  drain  was  left  in  both  wounds  and 
the  external  wounds  sutured.  The  week  following  the  operation  there 
was  some  discharge'  of  blood  and  debris,  but  no  active  hemorrhage. 
The  recovery  was  uneventful  and  complete. 

These  wounds  at  the  base  of  the  thorax  involving  the  diaphragm. 


IIO  WOUNDS    OF   SPECIAL   REGIONS. 

will  nearly  always  present  an  omental  hernia.  It  is  often  necessary, 
after  enlarging  the  thoracic  wound  by  resecting  a  rib  or  forming  a  costal 
flap,  to  resect  the  protruding  omentum ;  and,  at  the  moment  of  reduction 
of  the  stump,  one  may  have  an  unobstructed  view  of  the  wound  in  the 
diaphragm.  If  blood  oozes  from  it,  there  is  abundant  evidence  of  a 
wound  of  an  abdominal  viscus.  If  there  is  no  bleeding,  introduce  a 
finger  through  the  opening  in  the  diaphragm  and  examine  the  stomach 
and  adjacent  structures.  If  no  injury  is  found,  and  the  examining  finger 
is  not  covered  with  blood,  proceed  at  once  to  repair  the  diaphragm. 

A  curved  needle  is  best,  and  interrupted  sutures.  If  there  are 
wounds  of  the  abdominal  viscera,  they  may  possibly  be  repaired 
through  the  phrenic  wound;  and,  in  fact,  if  at  all  possible,  it  is  the 
method  of  election.  By  this  route  one  may  readily  reach  the  convex 
surface  of  the  liver  on  the  right  side,  or  on  the  left  the  greater  curvature 
of  stomach. 

Still,  if  the  exploration  is  difficult,  if  the  bleeding  is  abundant,  it  is 
better  to  lose  no  time,  but  to  do  a  median  laparotomy  at  once,  gaining 
additional  room,  if  necessary,  by  a  transverse  incision,  following  the 
costal  arch.  Subsequently  the  wound  in  the  diaphragm  may  be  re- 
paired through  the  thoracic  opening. 

Wounds  of  the  diaphragm  of  whatever  form,  perforations,  or  rup- 
tures due  to  crushing  injuries  to  the  chest,  are  likely  to  be  the  site  of 
herniae.   . 

Especially  in  the  latter  class  of  injuries,  must  one  be  on  his  guard 
for  this  injury.  Sometimes  there  are  certain  signs  which  point  at 
once  to  the  presence  of  a  diaphragmatic  hernia;  the  displacement  of 
the  heart,  the  bulging  of  the  lower  intercostal  spaces,  and  the  presence 
on  auscultation  of  sounds  which  in  no  way  resemble  the  vesicular 
murmur.  In  these  cases,  it  is  best  to  open  up  the  eighth  intercostal 
space  and  resect  the  ninth  rib,  which  will  usually  give  a  free  access 
to  the  site  of  injury. 

C.      WOUNDS    OF   THE   PERICARDIUM  AND   HEART. 

Not  every  precordial  wound  will  reach  the  heart.  Such  a  wound 
may  be  followed  only  by  a  slight  emphysema  and  is  to  be  treated  by 
aseptic  occlusion. 


\\t>i;\DS    OF    THE     PERICARDIUM    AM)    IIKART.  Ill 

If  the  wound  has  actually  penetrated  to  the  heart,  death  is  usually 
bo  rapid  that  no  measure  <>r  relief  can  be  considered.  K  it  is  a  gunshot 
wound,  death  results  from  shock  and  hemorrhage;  if  it  is  a  stab  <>r 
punctured  wound,  shock  plays  a  very  minor  part.  It  is  not  very 
likely  thai  any  small  size  stab  wound  of  the  heart  interferes  at  once 
seriously  with  the  heart's  action,  unless  it  involves  the  "coordination 
renter,"  which,  it  is  claimed,  lies  in  the  upper  third  of  the  inter-ven- 
tricular groove. 

If  the  wound  in  the  pericardium  be  small  or  valve-like,  the  blood  is 
retained  within  the  cavity  and  the  constantly  increasing  intra-peri- 
cardial  pressure  effects  the  softer  and  more  yielding  of  the  structures 
within  the  sac — viz.,  the  pulmonary  veins  and  the  descending  vena 
cava  and  the  auricles;  in  this  manner,  the  venous  current  to  the  auricles 
is  cut  off  and  the  agitated  heart  works  to  no  purpose.  The  sense  of 
oppression,  the  cyanosis,  and  venous  engorgement  all  bear  witness  to 
the  compression  of  the  auricles.  In  the  meantime,  the  pulse  grows 
miserably  weak  and  rapid;  the  apex  beat  is  lost,  the  heart  sounds  are 
muffled,  the  pericardial  dullness  is  augmented,  and  the  thoracic  wall 
bulged.  In  this  manner  from  "heart  tamponade,"  death  soon 
ensues.  If  the  wound  in  the  pericardium  is  large  and  the  pleura 
opened,  the  hemorrhage  rapidly  fills  the  pleura  producing  hemo- 
thorax, scarcely  less  distressing  than  the  hemo-pericardium. 

If  the  opening  in  the  thoracic  wall  is  free,  the  hemorrhage  is  external; 
the  blood  spurts  from  the  wound  or  wells  up  continuously,  uncon- 
trolled by  pressure  or  occlusion,  and  death  ensues  from  hemorrhage, 
simply. 

In  spite  of  all  this,  however,  a  wound  of  the  heart  is  not  to  be  con- 
sidered as  inevitably  fatal  and  beyond  surgical  skill.  The  number  of 
reported  cases  saved  by  timely  intervention  is  constantly  increasing 
and  will  increase  all  the  more  rapidly  as  time  goes  by.  Any  wound  of 
the  heart  sufficiently  large  to  produce  hemorrhage,  whether  external 
or  internal,  is  potentially  fatal. 

The  only  measure  of  relief  is  operation.  The  pericardium  is  to  be 
exposed   and   opened,   the  heart   relieved  of  pressure,   and  the  wound 

repaired. 
The  question  arises  as  to  how  late  an  operation  may  be  undertaken. 


112  WOUNDS    OF   SPECIAL    REGIONS. 

but  this  cannot  be  answered  by  a  general  formula;  as  long  as  there 
is  life,  there  is  hope  in  skillful  intervention.  In  the  cases  reported, 
the  great  majority  were  operated  not  later  than  six  hours  after  the 
injury. 

Regarding  the  location  of  the  wound  in  the  heart,  the  right  and 
left  sides  are  injured  with  equal  frequency,  but  the  ventricles  are  in 
much  greater  danger  than  the  auricle  in  the  proportion  of  seventeen 
to  one  (Vaughn).  The  external  wound  may  be  located  over  any 
intercostal  space,  but  the  great  majority  will  be  found  in  the  fourth, 
fifth,  and  third. 

Vaughn,  who  has  carefully  studied  the  statistics  of  operations  for 
these  injuries,  and  who  reports  his  second  successful  case  of  suture  of 
the  heart  (J.  A.  M.  A.,  Feb.  6,  1909),  offers  the  following  conclusions: 
that  there  is  no  longer  any  question  as  to  the  propriety  of  the  operation, 
but  that  its  mortality  is  probably  the  same  as  it  was  twelve  years  ago 
when  the  operation  was  first  introduced.  Probably  little  more  can  be 
done  to  prevent  death  from  hemorrhage,  but  the  prevention  of  the 
great  cause  of  death  following  the  operation,  infection  of  the  peri- 
cardium, remains  a  surgical  problem  yet  to  be  solved.  The  principles 
of  asepsis  and  drainage  as  applied  to  the  operation,  are  yet  to  be  more 
carefully  worked  out.     (See  Repair  of  Injury  to  Heart,  page  427). 

INJURIES  TO  THE  ABDOMEN. 

I.  Contusions. 

II.  Wounds. 

I.  Contusions  of  the  abdomen  occur  in  many"  ways;  they  may  be 
the  result  of  severe  blows,  the  kick  of  a  horse,  from  falls,  or  from  the 
crush  of  heavy  wheels  of  vehicles.  The  gravity  of  such  an  injury  is 
proportionate  to  the  amount  of  visceral  injury,  but  this  is  often  not 
apparent  from  the  first. 

Whether  the  viscera  are  injured  or  not,  there  is  always  some  degree 
of  shock.  In  the  first  hours  following  the  injury,  in  the  doubtful  cases, 
the  therapeusis  must  be  limited  to  the  treatment  of  shock.  If  trans- 
portation is  necessary,  it  must  be  done  with  the  greatest  care. 
•  Once  the  patient  is  placed  in  bed,  his  clothing  must  be  removed, 
his  head  lowered,  the  extremities  kept  warm,  and  repeated  injections 


IN!  I  K 1 1  S    I'd   Mil     ABDOMEN.  113 

of  normal  salt  solution  or  adrenalin  made,  as  tin'  charat  ter  of  the  shot  k 
indicates. 

In  the  meantime,  tin-  case  is  to  be  studied  and  it  is  to  he  decided 
whether  or  not  there  is  a  rupture  of  an  organ,  or  other  source  of 
hemorrhage. 

The  responsibility  is  a  heavy  one,  for  an  internal  injury  overlooked 
or  discovered  too  late,  is  likely  to  result  in  death.  The  patient  may 
rapidly  recover  from  the  shock,  but  this  by  no  means  proves  the  absence 
of  a  visceral  hurt. 

In  the  typical  case  of  grave  injury,  the  symptoms  of  shock  are  only 
temporarily  relieved  by  the  injections;  rather,  they  are  shortly  replaced 
by  those  of  internal  hemorrhage.  The  pulse  remains  small  and  fre- 
quent, the  skin  cold,  the  face  anxious  and  drawn.  The  abdomen  is 
distended  and  tender  to  the  least  pressure,  especially  in  the  zone  of 
direct  injury.  There  is  dullness  in  the  tlanks.  There  is  no  escape  of 
gas  from  the  bowels,  or  passage  of  urine.  The  patient  is  restless  and 
frequently  sighs,  and  seems  to  realize  his  impending  fate. 

In  such  a  case,  the  indications  are  plain.  There  can  be  no  excuse 
for  delay,  for  awaiting  the  signs  that  can  only  be  those  of  beginning 
peritonitis.     Prepare  for  an  immediate  laparotomy. 

But  suppose  the  case  is  not  accompanied  by  the  typical  symptoms. 
How  shall  we  determine  in  two  or  three  hours  whether  or  not  there  is 
a  grave  lesion?  A  conclusion  must  be  reached  from  the  study  of  two 
fat  tors:  (a)  the  pulse,  and  (b)  abdominal  tension. 

(a)  The  pulse,  disturbed  at  first  by  the  shock,  rapidly  approaches 
the  normal  perhaps,  but  within  a  half  hour  or  sooner,  it  can  be  deter- 
mined that  it  is  getting  weaker  and  more  rapid.  Such  a  change  is 
particularly  indicative  of  hemorrhage.  If  there  is  any  discrepancy 
between  the  pulse  and  temperature,  Lejars  insists  that  the  former  is 
the  safer  guide,  for  a  subnormal  temperature  resulting  from  shock 
may  persist  long  after  the  other  symptoms  have  disappeared. 

(b)  The  abdomen  may  or  may  not  be  swollen,  but  over  the  site  of 
the  injury  the  abdominal  muscles  soon  begin  to  grow  rigid,  and  resent 
the  least  touch,  under  which  they  may  be  felt  to  contract  and  stiffen. 
This  rigidity,  localized  ;it  first,  tends  to  spread  and  include  the  entire 
abdomen. 


114  WOUNDS    OF   SPECIAL    REGIONS. 

The  tension  is  usually  augmented  by  progressive  meteorism.  If  one 
has  attentively  observed  the  case,  it  will  be  seen  that  it,  also,  is  at  first 
localized,  but  rapidly  becomes  general. 

Dullness  in  the  flanks  is  a  valuable  sign  when  present,  but  its  absence 
settles  nothing.  It  may  be  masked  by  the  distended  stomach  and  in- 
testine; again  the  blood  may  not  collect  in  the  iliac  fossa,  but  may  flow 
directly  into  the  pelvic  cavity,  especially  if  the  hemorrhage  is  on  the 
left  side  of  the  mesentery. 

These  modifications  of  pulse  and  temperature,  of  abdominal  tender- 
ness and  tension,  must  be  taken  as  sufficient  indication  for  urgent  in- 
tervention; for  the  prognosis  does  not,  in  reality,  depend  more  upon 
the  nature  and  multiplicity  of  the  visceral  lesions  than  upon  the  time 
of  intervention,  for  every  hour  of  delay  adds  to  the  chances  of  infection 
and  sepsis — elements  which  the  early  operation  may  practically 
eliminate. 

Another  eventuality:  The  case  is  not  seen  until  infection  has  fixed 
itself  upon  the  peritoneum;  the  pulse  is  weak  and  rapid  and  progress- 
ively growing  worse;  the  temperature  is  subnormal,  the  extremities 
cold;  a  marked  tympanites,  with  persistent  vomiting,  perhaps  comes  on. 

Then,  indeed,  it  is  late  to  operate — especially  when  that  means  a  long 
and  tedious  laparotomy.  Every  doctor  must  answer  for  himself  the 
question,  "Is  it  too  late?"  As  Lejars  says,  we  must  extend  as  far  as 
possible  the  limits  of  intervention  in  such  cases,  for  it  is  the  last  re- 
source; and,  even  though  the  mortality  is  very  great,  the  occasional 
unexpected  recovery  legitimizes  the  operation.  (See  laparotomy  for 
traumatism,  page  469.) 

II.  Wounds  of  the  Abdomen* — Clinically,  these  fall  into  two  groups, 
(a)  those  in  which  there  is  doubtful  perforation  of  the  peritoneum, 
and  (b)  those  in  which  perforation  of  the  peritoneum  is  quite  obvious. 

(a)  The  patient  presents  himself  with  a  wound  of  the  abdominal 
parietes,  of  doubtful  depth.  It  is  easy  to  determine,  once  for  all, 
whether  the  peritoneum  has  been  perforated  (and  upon  that  the 
prognosis  depends)  by  passing  a  probe  or  grooved  director.  But  one 
should  certainly  do  nothing  of  the  kind.  There  is  a  definite  mode  of 
examination  to  which  one  must  rigidly  adhere. 
*For  gunshot  wounds,  see  pages  135  and  159. 


WOUNDS   OF   THE  ABDOMEN.  IIS 

Begin  by  a  hurried  inquiry  into  the  circumstances  of  the  injury, 
and  the  character  of  the  weapon.  Disinfect  the  hands  for  an  opera- 
tion. Finally  scrub  and  disinfect  the  abdominal  walls.  Not  until  this 
is  completed,  is  the  wound  ready  to  be  examined. 

Carefully  separate  the  lips  of  the  wound  with  finger  or  retractors; 
and,  as  you  proceed,  carefully  wipe  each  layer  as  it  is  exposed.  If 
necessary  to  facilitate  inspection,  enlarge  the  wound;  this  will  often 
be  the  case,  especially  where  the  vulnerating  instrument  has  entered 
obliquely. 

Dividing  the  various  layers,  the  peritoneum  is  reached  and  found 
intact;  there  is  no  oozing  from  below  the  level  of  the  muscular  layers, 
and,  if  this  finding  accords  with  the  other  signs  observed,  you  may  con- 
clude at  once  that  the  wound  is  non-penetrating.  In  such  a  case,  care- 
fully cleanse  the  wound  and  repair  each  layer  separately  by  continuous 
suture  with  catgut;  the  skin  with  silk  or  silkworm-gut;  cover  with  sterile 
gauze,  a  thick  layer  of  absorbent  cotton,  and  a  firm  abdominal  binder; 
and  thus  have  been  taken  the  best  steps  to  prevent  infection  or  ventral 
hernia,  which  is  often  the  result  of  these  wounds. 

If  the  wound  is  penetrating,  the  mode  of  procedure  depends  upon 
whether  it  is  a  (a)  narrow,  or  (b)  a  large  incised  wound. 

(a)  A  stab  wound  is  the  type — a  thrust  from  a  knife,  dagger,  or 
bayonet.  There  may  be  persistent  oozing  of  blood  alone,  or  blood 
mixed  with  bile  and  urine,  or  "food  products."  Such  a  mixture  is 
pathognomonic  of  visceral  injury,  but  nothing  can  be  decided  from 
its  absence. 

The  persistent  hemorrhage  is  strongly  suggestive  of  serious  injury 
to  an  organ,  especially  where  it  coexists  with  a  fading  pulse,  pallor, 
tympanites,  and  rigidity  and  tenderness  of  the  belly  wall;  yet  the  ab- 
sence of  all  these  signs  gives  no  assurance  of  the  absence  of  a  visceral 
injury. 

In  any  event,  then,  an  exploratory  laparotomy  is  indicated;  for  only 
by  that  means  can  one  assure  himself  of  the  conditions.  Ordinarily, 
the  wound  itself  is  enlarged  for  the  purpose  of  exploration,  but  in  the 
case  of  more  than  one  wound,  or  when  the  abdominal  walls  are  very 
thick,  it  may  be  advantageous  to  resort  at  once  to  median  laparotomy. 
In  either  case,  the  abdominal  opening  should  be  large  enough  for  rapid 


Il6  WOUNDS    OF   SPECIAL   REGIONS. 

work.  If  the  laparotomy  is  done  at  the  site  of  the  injury,  it  will  be  wise 
to  disarrange  the  viscera  as  little  as  possible,  when  sponging  out  the 
exudates.  Carefully  inspect  whatever  parts  present,  and  often  the 
lesion  will  be  revealed  by  this  first  search. 

If  a  median  laparotomy  is  done,  as  soon  as  the  cavity  is  opened 
proceed  to  the  site  of  the  injury;  cover  the  adjacent  coils  of  intestine 
with  compresses,  thus  preventing  their  possible  infection. 

The  lesions  are  only  rarely  multiple  or  difficult  of  repair  in  this  class 
of  abdominal  injuries. 

(b)  Extensive  Incised  Wounds. — These  wounds  are  produced  by  in- 
struments with  a  long  cutting  edge,  or  by  the  ripping  cut  of  small 
knives.     Horned  animals  occasionally  produce  them. 

The  chief  characteristic  of  these  wounds  is  eventration,  always 
present  .in  some  degree.  If  the  case  is  seen  immediately,  the  mode  of 
procedure  is  very  definite.  But  only  too  often  the  patient's  efforts  have 
augmented  the  hernia,  or  he  or  his  friends  have  made  untimely  at- 
tempts to  reduce  it. 

Having  cleansed  the  hands  and  the  abdominal  walls  in  the  usual 
way,  begin  next  a  systematic  cleansing  of  the  eventrated  mass.  Cleanse 
it  with  warm  sterile  water,  or  normal  salt  solution,  rubbing  gently  with 
the  fingers,  every  inch  of  the  projecting  bowel  or  omentum.  Only 
in  the  thoroughness  of  this  step  is  there  any  assurance  of  success.  If 
any  visceral  wounds  are  discovered  in  the  cleansing  process,  they  are 
to  be  repaired  at  this  time. 

Once  the  cleansing  and  repair  are  complete,  proceed  to  reduce  the 
hernia.  The  wound  may  need  to  be  enlarged;  if  this  is  necessary, 
slip  a  finger  under  an  angle  of  the  wound  to  serve  as  a  guide,  and  divide 
the  tissues  with  scissors.  The  other  angle  may  be  treated  in  the  same 
way.  Catch  up  the  peritoneum  with  forceps  along  the  whole  length 
of  each  side  of  the  wound.  Now  lift  on  the  forceps,  and  in  this  way 
create  a  sort  of  funnel  with  smooth  sides,  over  which  the  bowel  readily 
glides  in  reduction. 

Do  not  attempt  to  reduce  by  rough  pressure,  which  may  contuse  the 
bowel.     If  "taxis"  fails,  there  is  a  method  which  will  surely  succeed. 

Spread  a  large  compress  over  the  mass;  tuck  its  edges  well  under 
the  entire  circumference  of  the  wound;  and,  with  both  hands,  make  a 


WOUNDS    OP    THE    SPIN]  .  117 

gradual  pressure  on  the  mass  enveloped  in  the  compress,  coaxing  the 
refractory  Loops  into  place  with  the  fingers,  and  at  the  same  time  push- 
Rig  the  compress  further  under  the  abdominal  walls.  The  assistant, 
in  the  meantime,  lifts  up  on  the  Forceps  attached  to  the  peritoneum, 
raising  the  abdominal  walls  as  the  hernia  recedes. 

When  the  reduction  is  complete,  leave  the  compress  in  place,  se- 
cured by  forceps  until  repair  of  the  peritoneum  is  nearly  complete. 
Repair  the  abdominal  watt;  begin  by  suture  of  the  peritoneum  with  small 
catgut.  If  the  tension  is  great,  it  may  be  necessary  to  include  the  mus- 
cular plane  in  the  suture.  Xext  repair  the  muscular  layers  separately 
by  continuous  catgut  suture;  in  the  same  manner,  the  aponeurosis,  and 
finally  the  skin,  with  interrupted  silkworm-gut  sutures. 

Drainage  is  a  question  which  always  arises,  but  Lejars  assures  us 
that,  if  the  cleansing  is  carefully  carried  out,  drainage  is  in  no  wise 
necessary.  If  the  case  is  seen  late,  but  there  exist  only  a  few  soft  ad- 
hesions between  the  bowel  and  the  walls  of  the  wound,  the  same  dis- 
infection is  carried  out,  the  adhesions  around  the  orifice  gently  broken 
up,  and  the  mass  reduced,  as  before.  Drainage  is  quite  indispensable, 
if  there  are  already  the  signs  of  a  beginning  peritonitis. 

If  the  mass  has  become  the  site  of  a  purulent  peritonitis,  the  coils  ag- 
glutinated by  false  membrane,  and  gangrenous,  there  is  nothing  to  do 
except  to  keep  applied  moist  antiseptic  compresses,  which  must  be 
frequently  renewed.  If  the  patient  survives,  whatever  intervention  is 
needed,  may  be  undertaken  later.  (See  also  gunshot  wounds  of  ab- 
domen and  laparotomy  for  traumatism.) 

WOUNDS  OF  THE  SPINE. 

Wounds  of  the  spine,  even  in  their  slighter  forms,  require  a  guarded 
prognosis.  How  they  will  eventuate  can  never  be  certainly  foretold. 
Death  may  ensue  immediately  from  injury  to  the  cervical  part  of  the 
cord;or,  in  the  case  of  the  lumbar  region,  death  may  be  delayed,  but  is  as 
certain,  because  of  secondary  lesions.  Again,  recovery  may  ensue  but 
at  the  cost  of  paralysis,  variable  in  its  form  and  gravity.  Finally, 
recovery  may  appear  to  be  complete  and  even  then  years  after  some 
form  of  degeneration  may  manifest  itself  after  the  injury  has  long  been 
forgotten. 


Il8  WOUNDS    OF   SPECIAL   REGIONS. 

As  in  the  case  of  the  skull  the  whole  gravity  of  the  traumatism  de- 
pends upon  the  medullary  lesion.  The  treatment  must  of  necessity  be 
conservative;  only  when  the  cord  is  obviously  compressed  should  active 
intervention  be  considered. 

WOUNDS  OF  THE  VULVA  AND  VAGINA. 

The  chief  danger  in  wounds  of  these  parts  is  hemorrhage,  especially 
when  the  vulva  is  involved  and  its  venous  plexuses  torn.  These 
wounds  may  be  contused,  lacerated  or  punctured,  and  more  frequently 
occur  from  falls  astride  some  object,  and  by  that  means  the  bulb  of  the 
vagina  is  crushed  against  the  ramus  of  the  pubes. 

Forcipressure  and  ligation  may  be  ineffectual  to  control  the  bleeding 
and  often  the  only  recourse  is  tamponade,  first  disinfecting  the  wound 
and  the  region  adjacent,  and  afterward  applying  a  T  bandage  and 
bringing  the  thighs  firmly  together. 

Perforating  wounds  of  the  vagina  call  for  a  most  careful  examination, 
for  not  only  may  the  vaginal  walls  be  involved,  but  the  rectum,  bladder, 
or  peritoneum  as  well.  Careful  suturing  is  here  the  best  means  of 
controlling  hemorrhage.  Peritonitis  may  result  from  such  injuries 
or  more  remotely,  fistuke  or  astresia  of  the  vagina. 

Any  serious  hemorrhage  following  coitus  calls  for  an  examination. 
It  may  ensue  from  a  tear  of  the  hymen,  or  of  the  posterior  wall  of  the 
vagina.     Cases  are  on  record  in  which  the  tear  penetrated  the  rectum. 

Deep  suturing  serves  at  the  same  time  to  control  hemorrhage  and  to 
promote  repair. 

WOUNDS  OF  THE  PENIS,  SCROTUM  AND  TESTICLE. 

The  penis  may  be  fractured ;  and,  if  the  urethra  is  not  involved,  the 
hemorrhage  will  be  subcutaneous.  Unless  the  extravasation  is  very 
large  and  progressive,  there  is  nothing  to  do  but  to  bandage  the  organ 
and  put  the  patient  at  rest.  Otherwise  it  will  be  necessary  to  expose 
and  suture  the  break  in  the  corpus  cavernosum.  But  with  such  a  pro- 
cedure one  may  expect  a  severe  hemorrhage.  Open  wounds  of  the 
erectile  tissues  of  the  corpora  cavernosa  or  corpus  spongiosum  may  be 
expected  to  bleed  freely.     It  is  usually  advisable  to  pass  a  sound  to 


woinds  or    rni:  s<  im>i  i  m.  119 

determine  the  integrity  of  the  urethra,  suturing  it  first,  ii"  involved,  and 
then  carefull}  1  oapting  the  erectile  tissues. 

In  the  case  of  wounds  of  the  scrotum  merely  the  integuments  may 
be  penetrated,  or  more  deeply  the  tunica  vaginalis  or  the  testicle  as 
well.  It  must  be  remembered  that  any  considerable  wounding  of  the 
tunica  of  the  testicle  may  result  in  hernia  of  the  parenchyma. 

The  scrotal  tissues  must  not  be  roughly  handled  in  cleansing,  and 


F1G.I80. — Suture  of  wound  of  testicle.     A,  beginning  its  repair;  B,  wound  in 
l_  testicles  repaired.     C,  tunica  vaginalis.     (Lejars.) 

the  sutures  must  not  be  too  tight,  for  there  is  a  tendency  to  edema  and 
sloughing.  The  repair  of  these  various  structures  must  be  conducted 
separately. 

If  the  tunica  vaginalis  is  opened  up  and  the  testicle  herniated,  it 
must  be  carefully  cleansed  and  returned  and  the  tunica  sutured,  with 
or  without  drainage,  depending  upon  the  probabilities  of  infection.  If 
the  tunica  be  destroyed,  and  the  testicle  remains  sound,  it  must  be  pre- 
served, covering  it  as  much  as  possible  with  such  serous  covering 
as  remains.  Incised  wounds  of  the  testicle  call  for  suturing  of  the 
fibrous  coat  with  catgut. 

The  tunica  vaginalis  is  next  repaired  with  a  continuous  suture  (Fig. 
80),  and  finally  the  scrota]  wound  is  sutured. 

If  the  testicle  is  lacerated,  or  if  seen  late  and  manifestly  infected. 


WOUNDS    OF    SPECIAL    REGIONS. 


it  must  be  removed  without  delay.  Expose  the  spermatic  cord  as 
high  up  as  possible,  and  at  that  level  ligate  the  various  elements  sepa- 
rately and  firmly,  and  resect.  Trim  away  any  infected  tissues  in  the 
scrotum  and  repair,  making  drainage  (Fig.  8"i). 

Cotton,  of  Boston  (Amer.  Jour.  Urol.,  Nov.,  1906),  describes  a  case 
of  injury  to  the  testicle  resulting  from  a  blow  on  the  scrotum  by  a  batted 
base-ball.  Shock  and  excruciating  pain  ensued,  gradually  subsiding 
coincident  with  the  development  of  a  large  scrotal  hematoma. 


lnjJE 


Fig.  81. — Emergency  castration.     A,  transfixion  of  the  cord  and  ligature  of 
one-half.      B,  ligature  carried  around  the  entire  cord.      (Lejars.) 

Operation.  The  superficial  tissues  were  infiltrated  with  blood.  A 
rent  an  inch  long  in  the  tunica. vaginalis.  Bleeding  from  the  sper- 
matic artery.  The  tunica  albuginea  was  torn  in  shreds,  the  parenchyma 
destroyed.  "The  testis  had  evidently  exploded  under  the  swift  impact, 
as  a  full  bladder  bursts  under  a  blow."  After  removal  of  clots  and 
irrigation,  the  tissues  were  sewed  up  layer  by  layer  with  catgut  and 
without  drainage,  and  light  pressure  applied.  Convalescence  un- 
eventful. 


WOUNDS   OP    RECTI  \t.  121 

WOUNDS  OF  THE  RECTUM. 

Wounds  of  the  rectum  arc  rare.  'They  arc  usually  punctured  wounds 
due  to  falling  upon  pointed  objects,  gunshot  wounds,  or  tears  accom- 
panying fractures  of  the  pelvis.     The  chief  dangers  are  hemorrhage 

and  infection. 

Wounds  of  this  region  are  usually  self-evident,  though  their  extent 
may  be  a  matter  of  doubt,  so  that  every  such  injury  demands  a  care- 
ful examination.  The  examination  calls  for  inspection.  To  depend 
upon  touch  alone  may  lead  one  into  grave  error. 

In  every  serious  injury  of  this  character,  anesthetize  the  patient, 
dilate  the  anus,  and  by  the  use  of  retractors  expose  the  wound.  Douche 
\vith  hot  normal  salt  solution.  If  the  hemorrhage  persists,  the  bleed- 
ing points  are  to  be  clamped  with  long  forceps  and  an  attempt  made 
to  suture  en  masse,  for  at  that  depth  it  will  be  hardly  possible  to  ligate 
the  vessels.  Sometimes  in  lacerated  wounds,  the  oozing  can  be  con- 
trolled only  by  tamponing  the  rectum  firmly,  packing  around  a  large 
tube  in  the  center. 

Suturing  these  wounds  is  not  so  desirable  as  one  might  at  first  think, 
for  the  sutures  may  conduct  sepsis  to  the  deeper  tissues.  Do  not  suture, 
then,  unless  the  wound  is  easily  accessible,  recent  and  clean.  If  the 
sutures  are  used,  frequent  irrigations  of  normal  salt  solution  must  be 
employed  and  the  bowels  kept  quiescent  for  several  days. 

If  the  rectal  wound  has  penetrated  the  peritoneal  cavity,  which  fact 
may  develop  in  course  of  the  examination,  or  may  be  suspected  from 
the  tympanites  and  tenderness  of  the  abdomen,  the  better  plan  is  to 
proceed  to  a  laparotomy. 

The  abdomen  is  to  be  opened  in  the  middle  line,  the  patient  put  in 
the  Trendelenburg  position,  the  pelvis  cleansed,  and  the  wounds  re- 
paired by  two  tiers  of  sutures. 

If  the  small  intestine  should  become  herniated  through  a  rectal  tear, 
laparotomy  is  again  indicated,  reducing  tin-  hernia  by  traction  from 
above.  If  the  herniated  loop  protruding  from  the  anus  be  gangrenous, 
in  order  to  avoid  infection  of  the  peritoneum  the-  affected  segment 
Should  be  resected  and  the  two  ends  temporarily  ligated  before  pro- 
ceeding to  the  laparotomy.  Once  the  abdomen  is  opened,  the  two 
ends  of  the  bowel  are  to  be  pulled  up  and  anastomosed. 


CHAPTER  XI. 

GUNSHOT  AND  OTHER  WOUNDS  IN  MILITARY 
PRACTICE.* 

Gunshot  wounds  are  essentially  contused,  punctured,  or  lacerated 
wounds,  or  combinations  of  all  of  these,  differing  from  wounds  pro- 
duced by  other  means  only  in  their  potentialities. 

If  the  gunshot  wounds  of  military  service  differ  from  those  seen  in 
civil  practice  with  respect  to  their  character,  prognosis,  and  treatment, 
it  is  because  the  bullets  in  each  case  differ  with  respect  to  hardness, 
initial  velocity  and  range,  and  because  the  wounds  are  produced  in 
different  environments. 

The  modern  army  bullet  (Fig.  82)  is  of  small  caliber,  is  jacketed 
with  steel,  has  a  very  high  initial  velocity,  and  long  range.  At  close 
range,  such  a  missile  is  tremendously  destructive  to  all  the  tissues  alike, 
producing  the  conditions  of  crushed  or  lacerated  wounds. 

On  the  skin  at  medium  or  long  range,  the  wound  of  entrance  is 
small,  less  than  the  diameter  of  the  ball;  likely  to  be  dirty.  The  wound 
of  exit  is  larger,  more  irregular  and  bleeds  more  freely  (Fig.  83). 

The  pain  in  skin  wounds  is  often  moderate,  usually  a  burning  sensa- 
tion, and  the  shock  not  severe. 

The  fascia  presents  a  smaller  opening  than  the  skin,  the  fibers  being 
split,  rather  than  cut  in  twain,  and  for  this  reason  the  wound  tends  to 
close,  oftentimes  materially  interfering  with  drainage.  The  muscles 
are  contused,  lacerated,  and  are  likely  to  be  infiltrated. 

The  tendons  are  quite  likely  to  be  pushed  out  of  the  way  and  not 
wounded.     At  other  times,  they  are  partly  or  wholly  divided. 

The  blood  vessels  may  be  pushed  aside,  but  more  frequently  are  more 
or  less  torn,  and  one  of  the  frequent  causes  of  immediate  death  is  hemor- 

*  Authorities  specially  consulted:  Makins,  Stevenson,  Senn,  Von  Bergman, 
Fischer,  Havard,  De  Wreden,  Osuki,  and  various  contributions  to  the  Jour.  Assn. 
Military  Surg. 


INJURY    TO    NKRVKS 


123 


page.     Yet  even  in  the  case  of  laceration  of  large  arteries,  there  may 
be  spontaneous  hemostasis. 

Aneurism  (Fig.  84)  is  the  common  sequel  if  the  artery  is  grazed  or 
contused,  requiring  double  ligation  and  excision. 


Martini-Henry. 


Fie.  82. — Types  of  cartridges.     (Makins.) 
Guedes.  Lee-Metford.  Mauser.  Krag-Jorgensen. 


When  not  pushed  aside,  the  nerves  may  be  contused  or  divided,  re- 
sulting in  paralysis — immediate  or  remote — neuralgias,  or  trophic 
disturbances,  such  as  wasting  or  contracture  of  muscles,  or  blanching 
of  the  skin,  corresponding  to  the  distribution  of  the  nerve.  Even  though 
the  nerve  itself  is  not  injured,  these  conditions  may  result  from  its 


124  GUNSHOT  AND    OTHER    WOUNDS    IN   MILITARY   PRACTICE. 

inclusion  in  scar  tissue.     It  is  often  indicated  to  expose  the  nerve  and 
clear  it  of  exudates  or  to  attempt  suture  (see  repair  of  nerves). 

Bone  presents  a  wide  variation  in  the  character  of  the  lesions  pro- 
duced. There  may  be  mere  puncture,  there  may  be  extensive  com- 
minution, or  any  grade  of  injury  between  these  two  extremes  (Fig.  85). 


Fig.  83. — Showing  small  entrance  wound,  and  large  irregular  wound  of  exit.      (Makins.) 

The  character  of  the  injury  will  depend  upon  two  factors,  the 
character  of  the  bone  and  the  range  of  the  bullet. 

(a)  If  the  bone  is  soft  and  cancellous,  the  tendency  is  toward  per- 
foration; if  it  is  hard  and  compact,  the  tendency  is  toward  comminution. 

The  articular  end  of  the  long  bones,  the  short,  and  the  irregular 


CHARACTB  R    OF    BON]     l  I  SION. 


125 


bones  are  Likely  to  be  merely  perforated.  On  the  other  hand,  the 
shaft  of  the  long  bones,  the  skull,  the  scapula,  arc  much  more  likely 
to  be  shattered. 

(b)  At  long  range,  perforation  is  rather  to  be  expected;  at  very 
close  range,  comminution  is  the  rule. 

So  far  as  the  long  bones  are  concerned,  transverse  fracture  rarely 
occurs,  and  if  longitudinal  fracture  occurs,  its 
tendency  is  to  stop  short   of  the  articulation 
(Fig.  86). 

With  respect  to  the  bones  of  the  limbs,  it  is 
to  be  noted  that  the  exit  wound  will  be  the 
more  comminuted  (Fig.  87).  Perforating 
fractures  without  solution  of  continuity,  are 
often  difficult  of  diagnosis,  because  of  the 
absence  of  characteristic  symptoms.  The 
diagnosis  is  to  be  made  by  reference  to  the 
track  of  the  bullet,  palpation,  bone  dust  in  the 
wound  of  exit,  etc.  (Fig.  88). 

Comminuted  fractures  present  an  excessive 
mobility,  and  often  crepitus  is  hard  to  elicit. 
Owing  to  "local  shock,"  the  limb  may  be 
quite  powerless  and  yet  painless. 

Primary  shortening  is  often  absent  by  reason 
of  the  muscular  relaxation  due  to  shock.  Even 
though  healing  takes  place  uneventfully,  a 
large  amount  of  callus  is  likely  to  be  thrown 
out;  and,  for  a  long  time,  the  union  will  not  be  strong. 

Acute  osteo-myelitis  may  follow  infection.  On  the  other  hand, 
necrosis  may  occur  late  and  after  the  wound  has  apparently  quite 
closed. 

In  the  bones  of  the  skull  is  frequently  seen  the  so-called  "gutter 
fracture,"  in  which  there  are  usually  two  apertures  in  the  scalp,  con- 
nected   by    a    trench    ploughed    through    the   outer   table    and    diploe. 

(Figs.  89,90). 

The  corresponding  part  of  the  inner  table  is  comminuted  exten- 
sively and  perhaps  depressed. 


Fig.   84. — Traumatic 
aneurism.    (Mouttin.) 


126 


GUNSHOT  AND    OTHER    WOUNDS   IN   MILITARY   PRACTICE. 


The  length  of  the  gutter  depends  upon  the  surface  curvature,  and  the 
antero-posterior  are  more  serious,  as  a  rule,  than  the  transverse  (Fig.  91). 


Fig.  85. — Types  of  fracture  of  long  bones.      (Makins.) 
A*  primary  lines  of  stellate  fracture.     B,  stellate  on  one  side,  transverse  on  the  other. 
C,  complete  wedge  broken  out.     D,  incomplete  wedge.     E,  oblique  fracture. 

The  joints  present  effects  peculiarly  variant;  the  capsule  alone  may 
be  injured;  the  articular  ends  of  the  bones  may  be  guttered  or  pene- 


Fig.  86. — Lower  end  of  femur,  showing  tendency  to  fissures  to 
stop  short  of  articular  ends.      (Makins.) 

trated  with  or  without  injury  to  the  capsule;  there  may  be  much 
shattering,  fissures  radiating  in  all  directions;  or  the  joint  may  be  in- 


TYPES   OE   GUNSHOT    FRACTURE. 


127 


yoked  by  extension  from  the  wound  of  the  shaft.  The  bullet  may  be 
retained  in  the  joint  cavity.  Effusion  into  the  joint  is  a  constant 
symptom  following  perforation,  a  mixture  of  blood  and  synovial  fluid. 

Of  the  great  cavities  and  viscera,  each  has  its  own  particular  symp- 
tomatology. 

The  cranium,  according  to  Von  Bergman,  presents  the  following 


'AF 

Hi 

i 

1      m 

'."*-' 

BJ 

k 

ff^4  .  M< 

V 

S  ;  -  -     -  w 

WMSi                   B 

'-  jfflirt an  1  *    "-"  ■  - 

■M  ■',  QA               B  '■-■?•'" 
EH    '»  !           ■?'■'   •' 

< 

1 

1 

.-,  i 

1 

_B^HP 

Fig.  87- — Small  wound  of  entrance  and  large  wound  of  exit  of  left  leg.  Frag- 
ments of  bone  carried  to  right  leg  producing  large  irregular  wound  requiring 
amputation.      (Makins.) 


lesions:  at  short  range,  the  skull  and  scalp  are  torn  to  pieces;  at  160 
feet,  the  scalp  is  preserved,  hut  the  skull  is  shattered;  there  are  two 
Openings  with  lacerated  edges  with  brain  exudate,  the  wound  exit 
always  larger  than  that  of  entrance. 

At  320  feet,  there  arc  two  openings,  each  surrounded  by  a  series  of 
concentric  fissures  in  addition  to  radiating  fissures  (Fig.  92). 


128  GUNSHOT  AND    OTHER    WOUNDS    IN   MILITARY   PRACTICE. 


Fig.  88. — Oblique  perforation  implicating 
both  epiphysis  and  diaphysis,  with  large  frag- 
ment at  exit.      {Makins.) 


A 

-' 

mmm  - 

B 

>0?£33^ 

Fig.  89. — Transverse  section  of  "gutter"  fracture.      (Makins.) 
A,  no  loss  of  substance.      B,  Comminution. 


Gl  NSHCH     FRACT1  R I     OP    SKI  I  I  , 


12g 


At  1000  feet,  tin-  radiating  fissures  still  appear. 

At  5600  feet,  entrant  e  and  exit  wounds  are  clean-cut  holes. 

At  Sooo  feet,  there  is  only  the  wound  of  entrance,  and  the  bullet 
lodges  in  the  brain.  De  Wreden,  of  the  Russian  Army,  says  that  only 
beyond  a  range  of  1200  steps,  did  the  Japanese  bullet  perforate  so  as 
to  permit  of  recovery.  The  injuries  to  the  dura  mater  are  analogous 
to  those  of  the  skull. 


PlG.  'jo. — Gutter  fracture  perforating  skull  in  the  center  of  its  course.     (Makins.) 


The  brain  itself,  semifluid,  is  torn  to  pieces  at  short  range,  through 
bydrodynamic  action.  At  long  range,  the  bullet  merely  traverses 
the  brain,  producing  areas  of  contusion  in  the  neighborhood  of  its 
track.  There  may  be  a  diffuse  hemorrhage  throughout  the  brain,  the 
ventricles  being  Tilled  with  blood. 

The  symptoms  are  such  as  belong  to  concussion,  compression,  con- 
tusion, or  laceration  in  general. 
9 


130         GUNSHOT  AND    OTHER    WOUNDS   IN   MILITARY   PRACTICE. 

"The  vast  majority  of  gunshot  fractures  of  the  skull  are  accompa- 
nied by  more  or  less  marked  symptoms  of  brain  injury:  paresis  of 
certain  groups  of  muscles;  paralysis,  motor  and  sensory;  loss  or  im- 
pairment of  special  senses,  usually  sight  or  hearing;  Jacksonian 
epilepsy;  twitching  and  contraction  of  certain  muscles;  signs  of  brain 
irritation,  due  to  injury  of  the  cortex — in  fact,  all  the  symptoms  of  brain 
damage,  in  all  their  varying  combinations.  Usually  the  symptoms 
are  in  correspondence  with  those  to  be  expected  in  consequence  of  in- 
jury to  the  brain  cells  evidently  implicated,  but  occasionally  symptoms 


Fig.  91. — Superficial  perforating  fracture;  roof  lifted  at  both  openings.     (Makins.) 

arise  which  are  not  to  be  accounted  for  by  such  direct  inference;  they 
must  be  due  to  injury  to  outlying  portions  of  the  brain,  produced  by 
vibration  or  wave  action,  communicated  to  the  comparatively  fluid 
brain  by  the  passage  of  the  bullet."  (Stevenson,  Report  from  South 
African  War.) 

The  spine  is  seriously  injured  in  proportion  as  the  cord  suffers. 
Aside  from  the  cases  in  which  the  cord  lies  in  the  track  of  the  bullet 
and  is  partially  or  completely  divided  transversely  (Fig.  118),  there 
are  those  cases  in  which  there  is  no  anatomical  lesion  of  the  cord,  per- 
haps nothing  more  than  perforation  of  a  vertebra,  yet  the  functions  of . 
the  cord  are  markedly  depressed.     This  is  "concussion"  of  the  cord, 


..I  NSHOT    FRACTURE    OF    SKI  II 


131 


which   Makins  (Surgical   Experiences  in  South  Africa)  describes  in 
detail. 
The  degree  of  concussion,  and  therefore  the  degree  <>f  functional 

depression,  depends  dire<  lly  upon  the  velocity  of  the  ball. 

In  slight  spinal  concussion,  the  symptoms  consisl  in  loss  of  cuta- 
neous sensibility,  motor  paralysis,  and  vesical  and  rectal  incompetence, 

persisting  for  a  few  hours  or  even  two  or  three  davs. 


PlG.  93.      Ivxu-nsivcly  comminuted  gunshot  fracture  of  the  skull. 
(.SVnii  after  von  Hcrgmann.) 


Recovery  begins  with  return  of  sensation,  often  modified,  followed 
later  by  return  of  motor  activity. 

"Severe  concussion,  contusion  or  medullary  hemorrhage,   may  be 
considered  as  lesions  of  equal  degree  as  to  severity,  bad  prognosis,  and 
unsuitability  for  active  interference;  all  characterized  by  the  same- 
essential   phenomena,   viz.:   symmetrica]   abolition  of  sensation   and 
motility,  absence  of  any  sign  of  irritation  in  the  paralyzed  area,  and 


I32  GUNSHOT  AND    OTHER   WOUNDS    IN   MILITARY   PRACTICE. 

loss  of  patellar  reflex.  These  severe  injuries  are  all  accompanied  by 
profound  shock.  The  patient  lies  still,  with  eyes  closed,  great  pallor 
of  surface,  the  sensorium  benumbed,  the  pulse  small  and  irregular, 
respiration  shallow"  (Makins). 

In  addition  to  these  lesions,  there  are  such  as  arise  from  compression, 
either  of  bone  or  from  a  lodged  bullet.  But,  as  Makins  says,  it  may  be 
assumed  that  a  bullet  injuring  the  vertebra  sufficiently  to  displace 
bone,  has,  at  the  same  time,  produced  grave  lesions  of  the  cord.  If 
the  pressure  is  due  to  the  bullet,  it  argues  that  its  velocity  was  low 
and  that  there  may  be  no  serious  lesion  of  the  cord  and  that  the  symp- 
toms are  those  of  compression  alone.  Compression  due  to  extra-dural 
hemorrhage  can  rarely  produce  serious  symptoms. 

The  chief  surgeon  of  the  Russian  Army  in  the  Manchurian  cam- 
paign confirms  the  notion  previously  held  as  to  the  great  gravity  of 
wounds  of  the  spine. 

The  thorax  may  or  may  not  be  penetrated  by  the  impact  of  a  bullet, 
though  penetration,  of  course,  is  the  rule,  and  these  wounds  consti- 
tute a  large  part  of  the  casualties  of  battle.  The  non-penetrating 
wounds  present  no  features  of  especial  interest.  The  skin  and 
muscles  may  be  injured  in  various  degrees  between  simple  perforation 
and  serious  laceration.  The  clavicle  and  scapula  may  be  fractured; 
the  axillary  space  may  be  involved,  with  serious  results. 

The  penetrating  wounds  cross  the  thorax  in  every  direction,  trans- 
versely, longitudinally,  and  obliquely. 

Those  which  traverse  the  thorax  longitudinally,  and  are  received 
while  firing  or  advancing  in  the  prone  position,  are  noteworthy  in  that 
the  abdominal  cavity  is  usually  also  involved.  The  abdominal  cavity 
is  also  likely  to  be  penetrated  when  the  base  of  the  thorax  is  crossed. 

If  a  rib  is  involved,  the  bone  injury  is  usually  limited,  and  these 
fractures  are  considered  of  importance  only  when  the  intercostal  ar- 
tery is  wounded.  In  many  of  these  fractures  from  the  army  bullet, 
the  ordinary  symptoms  are  absent,  either  because  of  the  localized  char- 
acter of  the  injury  and  absence  of  contusion  of  the  soft  parts,  or  be- 
cause the  fragmentation  in  the  track  of  the  bullet  is  so  complete  as  to 
preclude  crepitus. 

The  lungs,  almost  certain  to  be  involved  in  perforating  wounds  of 


WOUNDS    OP   THE    EEART.  133 

the  chest,  escape  with   remarkably   slight    damage,   owing  to  their 
elasticity. 

"In  point  of  fact,  there  is  no  reason  why  a  perforation  by  a  small- 
caliber  bullet  should  be  much  more  feared  than  a  puncture  by  an  ex- 
ploring trocar,  and  the  danger  of  the  two  wounds  is  possibly   very 

nearly  the  same"  (Makins). 

Those  which  pass  near  the  root  of  the  lungs  are  very  likely  to  involve 
the  great  vessels,  followed  by  rapid  and  fatal  internal  hemorrhage. 

Certain  symptoms  manifest  themselves  in  most  cases  of  lung  injury 
in  some  degree.  Shock,  if  it  exists  at  all,  is  not  usually  serious  and 
arises  rather  from  the  injury  to  the  chest  wall;  nor  are  pain  and  dysp- 
nea  prominent. 

Colonel  Havard,  U.  S.  Military  Attache,  with  the  Manchurian 
Army,  instances  cases  where  soldiers  walked  twelve  to  eighteen  miles 
after  being  shot  through  the  lungs. 

Hemoptysis  is  fairly  constant,  but  not  persistent  longer  than  two  or 
three  days.     Cough  is  seldom  troublesome  and  pneumothorax  is  rare. 

Hemothorax  is  very  frequent,  but  in  the  great  majority  of  cases  is 
due  to  hemorrhage  from  the  chest  walls — to  the  intercostals  rather 
than  to  the  lung  injury  (Makins). 

The  symptoms  of  a  hemothorax  reach  their  full  height  on  the  third 
or  fourth  day.  The  pain  is  severe,  the  pulse  and  temperature  rise, 
dyspnea  is  prominent,  respiratory  movement  on  the  affected  side  is 
annulled,  and  there  are  the  physical  signs  of  fluid  in  the  pleura. 

The  course  of  the  temperature  is  a  matter  of  concern,  for  the  fever 
suggests  empyema.  It  seems  always  to  rise  pari  passu  with  the  in- 
crease of  blood  in  the  pleural  cavity,  often  declining  after  the  third  or 
fourth  day,  always  falling  after  a  paracentesis  and  rising  anew  with 
fresh  at  i  ess  of  pleural  hemorrhage.  On  the  other  hand,  the  fever  of 
infection  arises  later,  persists,  or  gradually  mounts  higher. 

Perforating  woundi  of  the  heart  in  warfare  Makin  regards  as  cer- 
tainly fatal,  believing  that  the  cause  of  death  is  not  hemorrhage,  but 
sudden  stoppage  of  the  heart  action. 

Semi  believes  that  death  usually  occurs  from  compression  of  the 
heart,  due  to  hemorrhage  within  the  pericardium.  In  those  cases 
where,  from  the  anatomical  features,  the  heart    would  seem  to  be  in- 


J34 


GUNSHOT  AND    OTHER    WOUNDS    IN    MILITARY   PRACTICE. 


volved  and  yet  presents  no  symptoms  of  injury,  the  inference  must  be 
that  it  escaped,  owing  to  change  in  position  and  size  incident  to 
contraction. 

Colonel  Havard  (Journal  Ass'n  Mil.  Surg.)  writes  of  the  Japanese 


Fig.  93. — Perforating  wounds  of  small  intestine.  A,  entry.  B,  exit. 
Note  slit-like  character  and  eversion  of  mucous  membrane;  localized 
ecchymosis  more  abundant  around  exit  aperture.  (Makins,  from  St. 
Thomas  Hospital  Museum.) 

bullet,  that  it  has  been  known  to  pass  through  the  heart  without  fatal 
effect. 

Penetrating  wounds  of  the  abdomen  are  seldom  simple  in  character, 
for  it  only  rarely  happens  that  a  single  viscus  is  involved.  The  one 
symptom  which,  if  it  occurs  as  all,  is  common  to  wounds  of  all  abdom- 


PENETRATING    WOUNDS   <>K   Till     ABDOMEN.  135 

inal  organs,  is  peritonitis.     The  sources  of  hemorrhage  are  numerous. 
The  degree  of  injury  to  every  organ  decreases  with  increased  range. 

The  small  intestine  is  naturally  the  structure  mosl  frequently  wounded 
and,  of  course,  its  perforations  are  multiple  (Fig.  93). 

Pain,  collapse,  vomiting,  and  peritonitis  are  nearly  always  present, 
although  present  also  in  wounds  of  the  stomach  and  large  intestine. 
The  peritonitis  is  more  widespread  in  the  case  of  the  small  intestine 
than  in  the  case  of  the  stomach  and  large  intestine,  because  of  the 
greater  activity  and  motility  of  the  small  intestine.  Vomiting  of 
blood  may  he  taken  to  indicate  perforation  of  the  stomach.  The 
stomach  and  intestines  escape  "explosive"  effects  in  proportion  as 
they  are  empty  at  the  time  of  injury. 

The  bladder,  when  wounded,  may  present  two  openings,  both  may 
be  extra-peritoneal,  both  may  be  intra-peritoncal,  or  one  may  be  intra- 
and  the  other  extra-peritoneal. 

An  extra-peritoneal  wound  bleeds  the  more  profusely;  an  intra-perit- 
oneal  wound  permits  the  escape  of  urine  into  the  peritoneal  cavity. 

Hematuria,  or  suppressed  urination  with  an  empty  bladder,  points 
to  the  character  of  the  injury. 

The  liver  is  likely  to  be  simply  perforated  or  notched,  though  at 
close  range  "explosive"  effects  are  observed.  The  chief  result  is 
hemorrhage  and,  in  some  cases,  an  escape  of  bile,  due  to  injury  to  the 
gall-bladder  or  the  bile  ducts. 

The  spleen,  if  merely  perforated,  gives  rise  to  hemorrhage,  usually 
insignificant,  unless  its  main  vessels  are  involved. 

The  kidneys  give  rise  to  either  extra-  or  intra-peritoneal  hemorrhage, 
which  is  not  serious  unless  the  perforation  involves  the  hilum.  Shock 
IS  nearly  always  present  as  well  as  hematuria  and  frequent  urination. 

The  pancreas:  there  is  no  way  by  which  injury  to  the  pancreas  may 
be  diagnosed.  It  may  be  merely  inferred  from  the  course  of  the  bullet. 
It  is  so  situated  that  it  cannot  be  reached  by  a  bullet  without  injury 
to  other  organs  more  likely  to  give  due  notice  o!"  their  affront. 

PROGNOSIS  AND  TREATMENT. 

Flesh   wounds,    uncomplicated,    heal    without    difficulty.     On    the 

field  of  battle  the  first-aid  dressing  is  applied,  and  in  the  simpler  cases 


136  GUNSHOT  AND    OTHER    WOUNDS   IN   MILITARY   PRACTICE. 

need  not  be  disturbed.  Ordinarily  it  will  need  to  be  changed  at  the 
field  hospital.  The  wound  is  to  be  regarded  as  an  aseptic  one,  unless 
the  contrary  is  demonstrated,  and  treated  as  such. 

Soap  and  water  as  a  means  of  sterilizing  the  skin  cannot  be  so  gener- 
ally used  as  in  civil  practice,  on  account  of  the  difficulty  of  supplying 
sterile  water  in  the  midst  of  a  campaign,  so  that  antiseptic  solutions 
must  often  suffice.     Tr.  iodine  is  the  most  convenient. 

If  the  bullet  has  lodged,  under  no  circumstances  is  it  to  be  probed 
for;  although  if  its  location  is  superficial,  it  may  be  removed  at  the 
time  of  the  first  dressing. 

The  aim  of  the  dressing  is  to  secure  antiseptic  occlusion,  and,  as 
much  as  possible,  immobilization. 

TREATMENT    OF    GUNSHOT   FRACTURES. 

The  treatment  of  gunshot  fractures  of  the  extremities  varies  in  de- 
tail, depending  upon  the  character  of  the  injury  to  the  bone  and  to  the 
soft  parts.  Three  clinical  varieties  may  be  recognized:  simple  per- 
forating fracture;  extensive  comminution  with  moderate  injury  to  the 
soft  parts;  and  extensive  comminution  with  great  laceration  and  de- 
struction of  soft  parts. 

(a)  The  treatment  of  simple  perforating  fracture  is  exceedingly 
simple, — is,  in  fact,  nothing  but  the  treatment  of  the  skin  wound,  viz. : 
aseptic  occlusion  and  immobilization.  The  result  is  invariably  good, 
provided  infection  is  kept  out  of  the  wound. 

(b)  By  moderate  injury  to  the  soft  parts  is  meant  more  or  less  en- 
larged wounds  of  entrance  and  exit,  without  extensive  laceration.  In 
such  a  case,  it  is  the  opinion  of  most  authorities,  that  conservatism 
will  give  the  best  results. 

The  skin  in  the  region  of  the  wound  is  sterilized  and  the  wound  also, 
if  obviously  infected,  although  it  is  usually  sufficient  to  cleanse  the 
skin — nothing  more — and  apply  an  antiseptic  dressing,  and  immobilize. 
A  variety  of  splints  are  available  for  the  fixation. 

"Immobilization  is  a  more  difficult  problem.  In  practised  hands, 
plaster-of-Paris  splints  answer  most  requirements,  except  in  the  case 
of  the  thigh ;  but  the  splints  take  time  to  apply  and  also  to  set  firmly,  and, 


TREATMENT   OF   <;i  NSHOT    WOUNDS.  137 

as  something  needing  frequenl  removal,  are  ool  altogether  suitable 

for  6eld  hospital  work.      Of  all  the  Splints  I    saw  in  use,  I   think  the 


Fig.  94. — Dutch  cane  field  emergency  splint  for  lower  extremity,     {Makins!) 

best  were  wire  splints  and  the  Dutch  cane  folding  splints  (Figs.  94,  95) 
for  the  thigh  and  Leg;  wire  gauze  splints  with  steel  margins  or  strips 
of  ordinary  card  board  applied  with  some  variety  of  adhesive  bandage 


i38 


GUNSHOT  AND    OTHER   WOUNDS    IN   MILITARY   PRACTICE. 


for  the  arm  and  forearm;  and  plain  wooden  splints  of  various  lengths 
for  any  situation."  (Makins,  Surgical  Experiences  in  South  Africa.) 
Senn  says,  referring  to  the  Spanish-American  war,  that  it  is  a  source 
of  regret  that  fixation  of  the  fractured  limbs  by  plaster-of-Paris  splints 
was  not  more  generally  practised.     Owing  to  the  want  of  reliable 


Fig.  95. — Cane  splint  for  upper  extremity.     (Makins.) 


plaster  of  Paris,  we  had  to  resort  to  various  kinds  of  splints  and  single- 
and  double-inclined  planes. 

In  some  cases  extension  will  also  be  required.  Transportation  is 
to  be  avoided  as  much  as  possible,  for  the  reason  that  it  always  aggra- 
vates the  difficulties  of  keeping  the  wound  sterile.     There  is  no  advan- 


I  Kl    \  1  M  1   \  I'    u|      ,,(    NSIHil      I  \i  \<    I  I    K  IS.  139 


age  which  transportation  will  situ  re  which  will  offset  the  advantage  of 
an  aseptic  wound. 

(c)  The  third  class  of  cases,  those  with  extensive  comminution  and 
treat  destruction  of  the  soft  parts,  always  raises  the  question  of  amputa- 
tion. The  question  of  viability  hinges  upon  the  blood  supply,  and  if 
it  is  determined  definitely  that  it  is  cut  off,  immediate  amputation  is 
indicated. 

On  the  other  hand,  if  the  blood  supply  is  yet  intact,  however  much 
the  bone  may  be  shattered,  it  is  advised  to  sterilize  the  wound,  get  the 
fragments  in  as  good  position  as  possible,  and  dress  antiseptically  and 
immobilize  as  before.  In  any  case  of  doubt  either  as  to  repair  or  in- 
fection, this  conservatism  is  proper. 

Later  a  line  of  demarcation  or  a  dangerous  sepsis  may  call  for  am- 
putation; on  the  other  hand,  the  suspected  tissues  may  heal  without 
interruption. 

If  infection  occurs,  osteomyelitis  may  arise  and  a  fatal  issue  is 
likely  in  such  a  case. 

Senn  sums  up  in  this  manner  the  modern  treatment  of  recent  gun- 
shot fractures: 

1 .  No  probing  of  the  wound. 

2.  No  primary  debridement. 

3.  Early  efficient  first-aid  dressing. 

4.  Immobilization  of  fracture,  preferably  by  plaster  splints. 

5.  Immobilization  combined  with  extension,  if  there  is  a  tendency 

to  undue  shortening. 

6.  First-aid   dressing   must   not   be   removed,    unless  this  becomes 

necessary  by  the  appearance  of  local  or  general  symptoms 
that  indicate  the  existence  of  wound  infection. 

Each  of  the  bones  of  the  extremities  presents  a  few  special  features, 
which  may  be  hurriedly  noted. 

The  humerus  is  quite  frequently  wounded.  The  most  characteristic 
Complication  is  musculo-spiral  paralysis,  either  immediate  or  remote. 
As  a  rule,  perforation  of  the  upper  end  gives  little  trouble  to  the  joint. 

The  ulna  and  radius  are  usually  injured  separately.  The  ulna,  on 
account  of  its  superficial  location,  is  often  the  seat  of  explosive  exit 
wounds.      This  is  also  true  of  the  lower  end  of  the  radius. 


140         GUNSHOT  AND   OTHER   WOUNDS   IN   MILITARY  PRACTICE. 

The  phalanges  suffer  much,  the  tendons  are  lacerated  and  acquire 
adhesions,  or  the  fingers  may  be  completely  carried  away. 

With  respect  to  the  treatment,  the  perforating  wounds  of  the  humerus 
are  cleansed  and  occluded.  The  comminuted  wound  is  wiped  clean 
of  debris,  an  ample  dressing  applied,  and  the  arm  immobilized  with 
light  splints.  Pasteboard  splints  are  as  good  as  any,  applied  wet, 
molded  into  shape,  and  fixed  with  adhesive  strips. 

Th.e  femur  is  quite  often  wounded  and  is  a  fertile  source  of  mortality. 


If!         s  M*         *         ■**  &t  & 

Fig.  96. — Hodgen  splint  for  fractured  thigh.     (Moullin.) 

There  is  a  tendency  to  great  shattering  of  the  shaft,  although,  owing 
to  its  deep  location,  the  wound  of  exit  is  rarely  "explosive."  Trans- 
verse fracture  is  rare.     Perforation  of  the  lower  extremity  is  common. 

These  fractures  are  nearly  always  accompanied  by  shock,  both  con- 
stitutional and  local.  As  a  result  of  local  shock,  shortening  is  often 
delayed,  only  to  be  quite  marked  when  the  muscles  regain  their  tone. 

The  prognosis  is  extremely  bad  in  the  case  of  the  upper  third,  but 
better  for  the  middle  and  lower  third.  Punctured  wounds  and  com- 
minuted fracture  with  small  skin  wounds  are  treated  by  aseptic  occlu- 
sion and  immobilization. 


Tk!  \l\ll  INT   01    Gl  NSHOT    WOUNDS   OP   JOINTS. 


141 


Comminuted  fracture  with  Large  wound  of  exit  requires  a  more 
formal  cleansing,  first  of  the  skin  and  then  of  the  wound,  with  removal 
of  the  fragments  of  hone  which  will  stand  no  chance  of  reunion.  The 
wound  is  not  sutured  and  drainage  is  usually  unnecessary.  If  trans- 
portation is  necessary,  plaster  of  Paris  is  the  safest  dressing. 

For  the  field  hospital.  Makins  recommends  some  adaptation  of  the 
Hodgen  splint  as  the  best,  most  practical,  and  efficient  {Fig.  96). 
Uncontrollable  hemorrhage,  great 
injury  to  the  soft  parts,  or  grave 
infection  calls  for  amputation;  but 
this  is  very  rare,  as  the  result  of  these 
wounds. 

The  tibia  and  fibula  present  condi- 
tions of  special  importance.  The  soft 
parts  are  often  severely  injured,  the 
vessels  are  implicated  and,  in  the 
case  of  the  ends  of  these  bones,  the 
joints  are  involved.  Suppuration  is 
common,  followed  by  secondary 
hemorrhage    and    purulent     arthritis 

(Fig-  97)- 

Conservative   treatment  is  the  best 
rule — asepsis,    careful    dressing,    im- 
mobilization.    In  ordinary  cases,  any 
form  of  splint  will  do,  but  the  plaster  of  Paris  is  probably  the  most 
satisfactory. 

The  fool  is  important  in  respect  to  these  injuries,  for  not  only  arc 
several  bones  involved,  but  also  several  joints.  Infection,  unfortu- 
nately, is  not  uncommon. 

The  first  dressing  must  insure  immobilization  in  a  good  position. 


Fig.  97. 


Perforation  of  lower  third  of 
tibia.      (Maki)is.) 


TREATMENT    OF    GUNSHOT    WOUNDS    OF    THE    JOINTS. 

Makins  says:  "We  had  merely  to  do  our  first  dressings  with  (are.  fix 
the  joint  for  a  short  time,  and  be  careful  to  commence  passive  motion 
as  soon  as  the  wound  was  properly  healed,  to  obtain,  in  the  great 

majority  of  cases,  perfect  results." 


142  GUNSHOT  AND    OTHER    WOUNDS    IN   MILITARY   PRACTICE. 

Infection  is  the  chief  danger.  If  suppuration  occurs,  an  immediate 
arthrotomy  is  indicated,  except  in  case  there  is  much  comminution  and 
disorganization,  when  amputation  will  be  the  safer  measure. 

The  shoulder- joint  may  be  involved  directly  or  by  fissure  from  the 
shaft.  Perforating  wounds  furnish  an  excellent  prognosis.  Aseptic 
occlusion  and  immobilization  usually  effect  a  cure  in  three  or  four  weeks. 
In  the  severer  cases,  cleanse  thoroughly,  ligate  bleeding  vessels,  restore 
the  parts  as  nearly  as  possible,  pack  lightly  with  gauze,  cover  amply, 
and  infection  will  usually  be  avoided. 

The  elbow  may  be  injured  along  with  the  humerus  and  ulna;  the 
prognosis  is  worse  when  the  humerus  is  involved.  The  olecranon 
may  be  perforated  without  injury  to  the  joint.  Anchylosis  is  frequent, 
but  even  if  suppuration  occurs,  a  good  joint  may  be  obtained.  The 
joint  is  immobilized  in  the  position  of  flexion. 

The  hip-joint  seems  not  to  be  very  frequently  wounded,  but  the  prog- 
nosis is  bad,  both  on  account  of  infection  and  complications,  such  as 
wounds  of  the  bladder,  rectum,  great  nerves,  etc. 

Anchylosis  and  shortening  in  an  abnormal  position  must  be  expected. 
Greatly  lacerated  wounds  call  for  amputation;  the  moderately  severe, 
for  conservative  treatment. 

The  knee-joint  is  very  frequently  wounded,  and  the  damage  is  always 
serious;  any  or  all  of  the  component  structures  may  be  injured.  Per- 
foration of  the  joint  without  injury  to  the  articular  surfaces  is  a  possi- 
bility. Hemorrhage  into  the  joint  is  a  constant  feature.  This  hemar- 
throsis  disappears  in  about  a  month  in  the  favorable  cases. 

Under  conservative  and  expectant  treatment,  the  results  are  sur- 
prisingly good.  On  the  battle  field,  the  wound  is  covered  with  a  first- 
aid  dressing,  and  some  sort  of  splint  applied.  At  the  dressing  station 
or  field  hospital,  the  dressings  may  be  removed  and  further  cleansing 
applied  if  necessary,  and  the  limb  immobilized  in  extension.  As  soon 
as  the  flesh  wound  has  healed,  passive  motion  is  to  be  begun.  If  sup- 
puration occurs,  arthrotomy  must  be  done  without  delay. 

The  ankle  is  usually  involved  along  with  several  bones  and  joints, 
either  directly  or  by  Assuring.  The  degree  of  comminution  is  variable. 
On  account  of  the  foot  coverings,  these  wounds  are  nearly  always  badly 
infected  and  phlegmons  are  frequent. 


iki\i\ti\i    OF   GUNSHOT    WOUNDS   0]     mi     SKULL.  [43 

For  these  reasons  secondary  amputations  arc  frequent,  1  >u t  the  treal 
niciii  must  be  conservative.     Immobilize  the  foot  at  a  right  angle  and 
he  on  guard  for  suppuration. 

I  Kl  A TMENT   ()!•'   GUNSHOT    WOUNDS    OF    THE   SKULL   AND    MRAIN. 

Perforating  wounds  of  the  skull  will  always  he  a  certain  source  of 
mortality.  The  fatalities  increase  as  the  range  shortens  and  as  the 
Rise  is  approached  (especially  the  hase  in  the  middle  and  posterior 
fossa),  due  to  destruction  of  the  automatic  centers  <>r  to  their  depression 
following  concussion,  hemorrhage,  or  intra-cranial  edema.  The  most 
recoveries  follow  injury  to  the  frontal  lobes  and  the  occipital  lobes, 
although  blindness  may  result  from  the  latter  class  of  injuries. 

Primary  union  of  the  scalp  wound  is  an  element  in  favorable  prog- 
nosis, since  by  this  means  infection  is  often  shut  out. 

First  aid  on  the  battle  field  will  look  to  the  hemorrhage  and  the 
use  of  the  first-aid  dressing,  which  should  aim  to  include  both  the 
wound  of  entrance  and  exit.  If  the  visible  hemorrhage  is  dangerous, 
do  not  pack  the  wound,  for  that  will  only  cause  compression.  A  few 
strips  of  sterile  gauze,  loosely  placed  in  the  wound,  will  favor  both 
hemostasis  and  antisepsis. 

At  the  dressing  station  or,  better  still,  at  the  field  hospital  if  the 
Symptoms  are  not  too  urgent,  a  craniectomy  must  be  done. 

All  surgeons  experienced  in  recent  wars  agree  on  the  necessity  of 
exploring  every  such  wound  as  soon  as  possible. 

Shave  and  cleanse  the  scalp  and  then  cleanse  the  wound.  Raise 
a  tlap  with  the  base  toward  the  blood  supply  and  with  the  entrance 
bullet  hole  in  the  center.  Enlarge  the  wound  in  the  skull  sufficiently 
to  introduce  a  finger  and  determine  the  presence  or  absence  of  frag- 
ments within  the  cavity.  Enlarge  the  wound  as  necessary,  to  clear 
the  brain  of  debris.  All  splinters  must  be  removed.  The  brain 
pulp  and  clots  are  to  be  wiped  out  with  sterile  gauze  and  the  wound 
closed  with  only  such  drainage  as  the  original  wound  of  entry  will 
afford.     (See  Urgent  Craniectomy.) 

The  subsequent  treatment  requires  the  patient  to  be  kept  as  quiet 

as  possible,  his  diet  limited  and  bowels  kept  open. 


144  GUNSHOT  AND   OTHER    WOUNDS    IN    MILITARY   PRACTICE. 

If  sepsis  occurs,  there  must  be  no  hesitation  in  reopening  the  wound. 

"Such  cases  of  sepsis  needed  secondary  exploration,  and  the  won- 
derful success  of  this  operation  was  perhaps  one  of  the  most  striking 
experiences  of  the  surgery  in  general."  (Makins,  Surgical  Experiences 
in  South  Africa.) 

TREATMENT   OF    GUNSHOT    WOUNDS    OF    THE   FACE. 

The  chief  dangers  in  gunshot  wounds  of  the  face  are  hemorrhage 
and  interference  with  respiration.  These  wounds  are  also  much 
predisposed  to  infection.  The  eye,  the  fifth  and  seventh  nerves  are 
most  likely  to  be  involved.  If  hemorrhage  cannot  be  controlled  by 
ordinary  means,  the  facial,  the  temporal,  or  even  the  external  carotid 
arteries  may  need  to  be  ligated.  Careful  cleansing  and  packing  with 
iodoform  gauze  secure  excellent  results. 

TREATMENT    OF    WOUNDS    OF    THE    NECK. 

These  wounds  are  always  dangerous,  and  yet  in  no  region  does  the 
unexpected  more  frequently  happen  in  the  passage  of  a  bullet.  The 
fact  of  hair-breadth  escape  of  important  structures  is  explainable  only 
by  the  small  size  of  the  army  bullet  and  the  mobility  of  the  structures. 
The  commonest  form  is  the  transverse  or  oblique  track.  Such  wounds 
as  are  not  immediately  fatal  are  likely  to  permit  recovery.  If  sepsis 
occurs,  it  usually  has  its  origin  in  the  air  passages  or  esophagus. 

Injuries  to  the  trachea  commonly  give  rise  to  broncho-pneumonia, 
hemoptysis,  or  emphysema. 

Many  patients  with  injury  of  the  esophagus  will  die  of  sepsis,  with 
perhaps  a  gangrenous  condition  of  the  esophagus.  Such  wounds  of 
the  large  vessels  as  do  not  produce  immediate  death  give  rise  to  many 
instances  of  arterio-venous  aneurysm. 

The  spinal  nerves  or  the  pneumogastric  may  be  injured.  If  the 
recurrent  laryngeal  is  divided,  hoarseness,  aphonia,  laryngeal  cough 
and  occasional  vomiting  will  be  the  result.  Stevenson  reports  cases 
with  injury  to  the  cervical  sympathetic,  in  which  the  most  prominent 
symptoms  were  suppression  of  sweating,  myosis,  and  pseudo-ptosis 


rREATMENT  OF  GUNSHOT    WOUNDS   01     mi      ABDOMEN.  145 

on  the  injured  side.    As  a  rule,  no  special  treatment  aside  from  ami 
gepsis  is  required.     Tracheotomy  may  Ik-  called  for;  and  it*  the  spine 
is  fr.u  lured,  immobilization  will  he  necessary. 


tk  1  \1\11  \i    op   \\<m  nds  OF    I'll  I',  simm:. 

These  wounds  are  so  extremely  fatal  that  nothing  more  need  he  said 
of  the  treatment  than  that  it  should  he  conservative  and  the  patient 
should  he  moved  as  little  as  possible.  If  the  patient  survives  with 
pressure  symptoms  then  later  on  a  laminectomy  is  to  be  considered. 

TREATMENT    OF    WOl   NDS    OF    THE    THORAX. 

The  non-perforating  wounds  need  only  an  antiseptic  dressing. 
Broken  ribs  will  require  adhesive  strapping. 

The  perforating  wounds  presenting  no  special  indications  of  hemor- 
rhage from  the  chest  wall  are  to  be  treated  by  aseptic  occlusion. 

The  internal  mammary  or  the  intercostal  arteries  may  need  to  be 
controlled.  If  the  hemorrhage  is  visceral,  opium  and  compression  of 
the  chest  wall  by  firm  bandaging  seem  to  be  the  last  resort  in  time  of 
war.  Under  no  circumstances  is  the  wound  to  be  probed  or  examined 
with  the  linger.  Transportation  is  always  to  be  feared.  In  every 
way  the  patient  is  to  be  kept  as  quiet  as  possible.  He  must  be  made 
,  to  realize  the  seriousness  of  his  injury.  Paracentesis  should  not  be 
performed  in  the  case  of  hemothorax  until  the  bleeding  has  ceased.  Thorac- 
otomy is  to  be  performed  if  suppuration  occurs.  (See  Injuries  of 
Thorax.) 

IKI   VIMI'.N'T    OF    GUNSHOT    WOUNDS    OF    THE   ABDOMI  \. 

N'on  perforating  wounds  require  only  aseptic  occlusion.  Perfora- 
ting wounds  are  always  to  be  regarded  seriously,  yet  uncomplicated 
wounds  of  the  solid  viscera  heal  without  difficulty.  Of  the  hollow 
viscera,  the  ascending  and  descending  colon  and  cecum  give  the  best 
prognosis  following  perforation.  The  stomach  is  not  quite  so  favorable 
and  the  transverse  colon  and  small  intestine  give  the  worst  prognosis. 


146         GUNSHOT  AND    OTHER    WOUNDS    IN    MILITARY   PRACTICE. 

Undoubtedly,  recovery  may  follow  perforation  of  even  the  small 
intestine  by  the  army  bullet. 

"The  innocuousness  of  the  abdominal  wounds  inflicted  by  the 
Japanese  bullet  is  often  wonderful.  *  *  *  *  Of  perforating 
wounds  of  the  abdominal  cavity,  twenty-five  cases  came  under  treat- 
ment; no  operation  was  possible  or  attempted.  Within  twelve  days, 
seven  died,  a  mortality  of  28  per  cent.  Some  of  these  cases  had 
travelled  forty  miles  in  rough  carts,  others 'came  on  horseback;  only 
a  few  were  brought  on  stretchers;  eight  arrived  with  peritonitis.  That 
only  seven  died  under  such  condition  is,  indeed,  most  remarkable." 
(Colonel  Valary  Havard,  Ass't  Surg.-Gen'l,  U.  S.  A.  in  the  Journal 
Ass'n  Military  Surgeons.) 

In  warfare  practice,  nearly  all  authorities  reluctantly  admit  the  in- 
efficiency of  operative  treatment  for  this  class  of  gunshot  injuries,  and 
the  better,  though  unsatisfactory  results,  of  conservative  treatment. 

SHELL  AND  SHRAPNELL  WOUNDS. 

These  wounds  are  for  the  most  part  lacerated  wounds,  although 
some  of  the  smaller  fragments  of  shell  (Fig.  98)  or  the  round  balls  of 
the  shrapnell  (Fig.  99)  may  produce  perforating  wounds  resembling 
those  of  bullets. 

Naturally,  a  large  proportion  of  such  wounds  will  be  fatal,  laying 
open  the  great  cavities,  lacerating  the  viscera,  or  mangling  the  limbs. 

They  are,  in  effect,  infected  wounds  and  are  to  be  treated  on  the 
general  surgical  principles  applicable  to  infected  lacerated  wounds. 

The  leaden  bullets  of  shrapnell  are  often  retained  and  are  to  be 
removed  except  when  sunk  in  the  chest,  abdomen,  or  pelvis. 

BOLO  WOUNDS. 

According  to  Foxworthy  (Ft.  Wayne  Medical  Journal,  June,  1902), 
every  insurgent  in  the  Philippines  was  armed  with  a  bolo.  "This  bolo 
was  of  iron  with  a  wood  or  bone  handle  and  varied  in  shape  and  size 
from  a  sword  to  a  dagger  and  from  a  corn  knife  to  a  meat  ax.  It  was 
generally  a  cruder  weapon  than  the  Cuban  machete,  but  every  effective 


B01  0    WOUNDS. 


147 


in  close  encounters.  As  it  could  be  <  on<  ealed  beneath  the  loose  ja<  ket, 
it  was  more  serviceable  than  .1  sword  or  saber,  whi<  h  was  always  visible. 
The  kries  is  a  weapon  similer  to  the  bolo,  but  with  a  wavy  edge  like 
a  Christy  bread-knife.  It  is  often  two  edged.  The  wounds  produced 
by  the  bolo  and  kries  were  often  of  great  length  and  usually  infected. 
"Another  class  of  wounds  was  caused  by  spears  and  tomahawks, 
used  by  the  [gorrotes  and  Negrites.     The  tomahawk,  havingacon- 


Pig.  98.— Fragments  of  Vickers  Maxim  one-pound  shell.     {Makins.) 

cave  edge,  was  not  so  apt  to  glance  off  the  skuH  as  an  Indian  tomahawk. 
A  blow  split  the  skull  wide  open. 

"The  spears  were  often  of  bamboo,  sharpened  to  a  fine  point,  and 
their  penetrating  power  was  almost  equal  to  thai  of  an  iron-tipped 
spear.  The  iron-tipped  spear  had  from  one  to  four  barbs  which  made 
an  exceedingly  ugly  penetrating  wound  and  usually  had  to  be  cut  but. 
These  wounds  were-  always  infected  and  tetanus  frequently  developed." 


148  GUNSHOT  AND    OTHER    WOUNDS   IN   MILITARY   PRACTICE. 

FIRST  AID  ON  THE  BATTLE  FIELD. 

Colonel  Nicholas  Senn,  in  his  address  before  the  Lisbon  International 
Medical  Congress,  1906,  has  accurately  defined  the  principles  of  first 
aid  on  the  battle  field,  and  his  conclusions  are  herewith  summarized: 
(1)  The  fate  of  the  wounded  depends  largely  upon  the  time  and 


Fig.  99. — Normal,  deformed,  and  fractured  leaden  shrapnel  bullets.     (Makins.) 


thoroughness  with  which  first  aid  is  rendered.  This  first  aid  for  many 
reasons  cannot  be  rendered  by  the  surgeon,  but  must  be  given  by 
comrades  or  by  the  wounded  man  to  himself.  First  aid  administered 
in  this  manner  will  be  effective,  owing  to  the  aseptic  character  of  the 
chief  wounds  of  battle,  if  previous  instructions  have  been  given.  It  is 
absolutely  essential  that  the  soldier  should  receive  this  elementary  in- 
struction when  he  is  taught  the  art  of  war,  arid  it  should  not  be  post- 


FIRST   All'    ON     I  III      i:\llll      FIELD. 


149 


poncd  as  has  been  done  only  too  often  in  the  past  until  war  ( louda 
make-  their  appearance. 

(2)  The  first-aid  dressing  should  combine  simplicity   with  safety 

against  post-injury  infection.  It  should  be  on  the  person  of  every 
combatant  and  must  be  simple  to  be  efficient.  It  must  be  compact 
and  easy  of  application. 

"The  dressing  consists  essentially  of  two  pads  of 
cotton,  wrapped  in  gauze,  and  fastened  together 
by  two  stitches  and  continuous  with  a  gauze 
roller,  which  is  made  use  of  instead  of  the  triangular 
bandage  for  holding  the  dressing  in  place  and  for 
immobilizing  the  injured  part.  The  gauze  roller 
should  take  the  place  of  the  triangular  bandage  in 
every  first-aid  dressing  as  it  requires  much  less 
space  and  is  more  serviceable  as  a  means  of  fixa- 
tion and  support. 

"The  brown  iodine  spot  in  the  center  of  the  pad 
on  the  side  to  be  brought  in  contact  with  the 
wound,  corresponds  with  the  location  of  the 
antiseptic  powder  incorporated  in  the  absorbent 
cotton  and  serves  as  an  infallible  guide  in  applying 
the  pad  in  the  right  place." 

(3)  The  first  aid  must  have  in  view  the  treat- 
ment of  shock  and  hemorrhage,  dressing  of  the 
wound,  and  immobilization  of  the  injured  part. 

The  treatment    of    shock    in    the    field    is    very      fig.  xoo.—  Eleva- 

.   f  .  -  ,  ,        ,  tion  of  the  upper  ex- 

unsatisfactorv,     but,     fortunately,     Shock    IS    not    a    tremity  in  the  treat- 

1  -re  11        vu       u    li   j  1  tj      i.    ment  of  hemorrhage. 

characteristic  of  small-caliber  bullet  wounds.     Rest  (Smn.) 

in  the    recumbent  position;   hypodermic    injection 

of  1/4  grain  of   morphia;    spirits  internally — these  answer  the  most 

urgent  indications. 

The  treatment  of  hemorrhage  at  the  front  must  be  conducted  with 
the  greatest  caution.  Elastic  constriction,  if  too  generally  practised, 
will  do  vastly  more  harm  than  good.  It  should  be  applied  only  in 
exceptional  cases  and  then  by  a  competent  member  of  the  hospital 

corps  or  a  medical  officer,  who  must  make  it  his  duty  to  send  the  case 


IS© 


GUNSHOT  AND    OTHER    WOUNDS    IN    MILITARY   PRACTICE. 


to  the  first  dressing  station  as  quickly  as  possible,  where  definitive 
hemostasis  can  take  the  place  of  the  constrictor.  There  are  less 
harmful  means  of  hemostasis  which  will  be  efficient  in  most  cases: 
elevation  of  the  limb  (Figs,  ioo,  101),  acute  flexion  of  the  joint  above 
the  wound  (Figs.  102,  103),  digital  compression  over  the  dressing — 
these  are  measures  which  must  be  taught. 

Direct  treatment  of  internal  hemorrhage  of  any  of  the  large  cavities 


Fig.  ioi. — Gun-stack  for  elevation  of  the  lower  extremity.      (Senn.) 


is  entirely  out  of  the  question  at  or  near  the  firing  line.  The  car- 
tridge belt,  suspenders,  or  gunstrap  can  be  used  to  the  greatest  ad- 
vantage in  limiting  respiratory  and  abdominal  movements  and  thus 
secure  for  the  vascular  bleeding  organs  a  condition  of  rest,  conducive 
to  spontaneous  arrest  of  hemorrhage  (Fig.  104). 

Immobilization  is  an  essential  part  of  first-aid  treatment,  conducing 
to  primary  repair,  relieving  pain,  and  preventing  infection  by  securing 
the  first-aid  dressing. 


FIRST    \ll>    ON     I  III      l.\  ITU     FIELD. 


IS' 


The  ideal  fixation  splint  in  such  cases  would  be  the  plaster-of-Paris 

splint,  hut  this  method  of  fixation  is  entirely  out  of  the  question  on 
the  firing  line  and  must  be  reserved  for  tin-  dressing  station  or  field 
hospital.  This  first-aid  fixation  must  he  extemporized.  The  sound 
leg  may  serve  as  a  splint  for  the  wounded  one  which  is  held  in  place 


Fie.  102. — Forced  flexion  of  forearm  in  arresting  hemorrhage  from  the 
brachial  artery  opposite  the  elbow-joint  or  any  of  its  branches  below 
this  point.      (Scun.) 


by  belt,  gunstrap,  handkerchief,  etc.     Tin-  rifle,  bayonet,  and  saber 

are  always  available  as  splints  (Figs.  105,  106,  107). 

A  fractured  humerus  may  be  splinted  to  the  side  of  the  body.     A 
well-padded  bayonet  will  meet  the  indications  in  fracture  of  the  fore 
arm.     The  wire  netting  cut  in  the  shape  corresponding  to  the  fixation 
of  the  different  fractures  of  the  limbs  should  be  carried  to  the  front  by 


152 


GUNSHOT  AND    OTHER    WOUNDS   IN   MILITARY   PRACTICE. 


the  sanitary  corps  in  sufficient  quantities  to  meet  the  expected  require- 
ment. Splints  made  of  this  material,  well  padded,  will  answer  an  ex- 
cellent purpose'  as  first-aid  fixation,  as  they  can  be  molded  into  shape 
and  can  be  used  subsequently  to  strengthen  the  plaster  bandage  at  the 
dressing  station. 

(4)  The  first-dressing  station  is  the  most  important  place  for  skilled 
aid.  This  primary  depot  of  the  wounded  should  be  established  in  a 
sheltered  place  as  near  as  possible  to  the  firing  line,  protected  as  much 
as  possible  against  the  fire  of  the  enemy.  . 

(5)  Probing  of  recent  gunshot  wounds  must  be  prohibited  by  the 
most  stringent  rules.     Under  no  circumstances  should  attempts  be 


Fig.  103. 


-Genuflexion  in  the'treatment  of  hemorrhage  from  the  popliteal  artery 
and  its  branches.     (Senn.) 


made  to  remove  bullets  until  this  can  be  done  under  strict  aseptic 
precautions  in  the  hospital,  and  then  only  in  those  cases  in  which  such 
operation  is  clearly  indicated  and  the  exact  location  of  the  bullet  has 
been  determined  by  palpation  through  the  intact  skin  or  by  the  use  of 
the  "X-ray." 

(6)  The  surgeon's  most  important  duties  at  the  first-dressing 
station  are: 

(a)  Inspection  of  first-aid  dressing.  If  it  is  in  its  proper  place,  label 
to  this  effect  that  it  may  not  be  unnecessarily  removed  at  the  hospital. 
If  defective,  it  must  be  renewed  or  more  securely  fastened. 

(b).  Application  of  plaster  splints  to  the  fractured  limbs;  the  wire- 
netting  splints  are  cut  into  strips  and  incorporated  in  the  plaster-of- 
Paris  dressing. 


THK    FIRST   l'kl  SSINC    STA'I  1"V 


153 


(c)  Emergency  Operations.    The  operative   treatment  of  gun.-liot 

wounds  must  be  limited  to  the  most  urgent  cases.  The  definitive 
arrest  of  hemorrhage — of  dangerous  external  or  internal  hemorrhage — 
stands  pre  eminent  in  the  list  of  emergency  operations.  Iodized  cat- 
gut is  the  proper  ligature  material  for  field  servii  e. 

Intra-cranial  and  intra-thoracic  hemorrhage  should  not  he  interfered 
with  outside  of  a  well-equipped  hospital. 
Dangerous  intra-abdominal  hemorrhage  calls 
for  prompt  operative  interference.  Abdom- 
inal section  under  such  circumstances,  in  a 
tent,  may  contribute  much  in  lessening  the 
mortality  from  hemorrhage  by  a  resort  to 
ligature,  suture,  or  aseptic  tamponade. 

By  pursuing  this  aggressive  course,  some 
lives  .may  be  saved  by  prompt  interference 
which  would  be  lost  by  the  let-alone  treat- 
ment. Wounds  of  the  larynx  and  trachea 
which  have  given  rise  to  respiratory  difficul- 
ties, either  from  emphysema  or  hemorrhage, 
call  for  an  immediate  tracheotomy. 

Resection,  as  a  primary  operation  for  pene- 
trating gunshot  wounds  of  the  joints,  is 
obsolete. 

Amputation  must  be  reserved  for  cases  in 
which  a  limb  has  become  mangled  by  a  can- 
non ball  or  fragment  of  shell  or  in  which  the 
fracture  is  complicated  by  division  of  the 
principal  blood  vessels  and  nerves. 

Laparotomy  in  the  field,  for  gunshot  wounds  of  the  abdomen,  with 
a  view  of  finding  and  suturing  perforations  of  the  gastro-intestinal 
canal,  has  not  yielded  in  practice  the  anticipated  results,  and  hence 
must  be  restricted  to  exceptional  cases. 

Clinical  experience  has  shown  that  in  a  fair  percentage  of  cases 
penetrating  wounds  at  and  above  the  level  of  the  umbilicus,  inflicted 
in  the  antero-posteriiir  direction,  do  not  implicate  the  gastro-intestinal 
canal,  and  in  such  cases  conservative  treatment  yields  better  results 


Fig.  104. — Temporary 
treatment  of  penetrating 
wound  of  chest  by  antiseptic 
tamponade  and  immobiliEa- 
tion  by  circular  compression. 
(5<.->iu.) 


154  GUNSHOT  AND    OTHER   WOUNDS   IN   MILITARY   PRACTICE. 

than  operative.     On  the  other  hand,  in  wounds  involving  the  small 
intestine  area,  more  especially  when  the  bullet  takes  an  oblique  or 


Fig.  106. — Gun  splint.     (Senn.) 


Fig.  107. — Stick  and  blanket  splint.      (Senn.) 

transverse  course,  we  may  confidently  expect  to  find  from  three  to 
fifteen  perforations,  and  it  is  this  class  of  cases  in  which  immediate 
laparotomy  offers  the  only  chance  of  saving  life. 

(7)  The  surgeon's  field  case  should  be  light,  compact,  and  the  in- 
struments wrapped  in  a  canvas  roll,  so  that  instruments  and  envelope 
can  be  quickly  sterilized  in  boiling  soda  solution. 


CHAPTER  XII. 
GUNSHOT  WOUNDS  IN  CIVIL  PRACTICE. 

The  projectiles  of  the  ordinary  fire-arms  of  civil  life  differ  from 
those  used  in  warfare,  in  that  they  are  composed  of  soft  lead,  are  easily 
deformed,  are  of  slight  initial  velocity,  and  are  usually  fired  at  short 
range. 

The  revolver  and  pistol,  flobert  and  shot-gun  produce  the  wounds 
most  frequently  seen. 

Of  the  shot-gun  it  may  he  said  that  the  wounds  which  it  produces 
arc  very  likely  to  be  either  greatly  destructive  or  comparatively  harm- 
less. At  close  range  the  charge,  acting  as  a  single  body,  lacerates  and 
shreds  the  tissues;  at  long  range  a  number  of  small  perforations  are 
math'. 

The  dangerous  wounds,  then,  have  all  the  characteristics  of  lacera- 
ti  >ns  and  demand  the  treatment  of  lacerated  wounds  in  general.  It 
must  always  be  assumed  that  foreign  bodies  have  been  carried  into  the 
tissues  and  that  these  wounds  are  therefore  infected. 

It  is  the  bullet  wound  of  the  revolver,  however,  which  it  is  most 
practical  to  consider.  To  a  limited  extent,  its  pathology  is  similar 
to  that  of  the  army  bullet,  and  it  is  unnecessary  to  state  again  the 
cffci  t  of  a  bullet  upon  the  various  tissues.  It  is  expedient  to  consider 
at  once,  with  especial  reference  to  treatment,  the  bullet  wounds  of 
certain  localities. 

WOUNDS  OF  THE  HEAD. 

The  region  of  the  brain  is  usually  wounded  in  attempts  at  suicide, 
and  it  is  the  right  temple  or  forehead  which  is  mosl  frequently  -elected. 
The  vertex,  postero-lateral,  and  occipital  regions  are  seldom  wounded 
and  only  then  as  a  result  of  accident  or  assault. 

As  medico-legal  questions  are  often  involved  in  these  cases,  it  is  a 

'55 


156  GUNSHOT   WOUNDS   IN   CIVIL   PRACTICE. 

wise  practice  to  make  careful  and  systematic  examinations.  Learn 
as  much  as  possible  about  the  character  of  the  fire-arm,  the  nature  of 
the  projectile,  the  position  of  the  patient  at  the  time  of  injury.  Ex- 
amine the  ears  and  nose  for  blood,  inspect  the  mouth,  examine  the  head 
for  a  wound  of  exit,  or  see  if  the  bullet  can  be  located  beneath  the  scalp. 

Next  examine  the  wound  itself,  but  not  until  the  field  and  wound 
have  been  sterilized.  Begin  the  disinfection  by  shaving  the  scalp 
about  the  wound.  Wash  with  soap  and  water  and  then  with  alcohol 
or  bichloride. 

Enlarge  the  wound  by  a  cross  incision,  if  necessary,  and  wipe  out  with 
sterile  gauze,  removing  all  forms  of  foreign  bodies. 

Finally  examine  the  skull.  If  you  find  a  mere  depression  without 
penetration,  it  is  sufficient  to  pack  the  opening  with  sterile  gauze  and 
bandage.  Later  the  bullet  may  be  located  with  the  "X-ray"  and 
removed,  if  it  becomes  troublesome.  If  the  bullet  is  visible  and  re- 
movable without  much  difficulty,  it  is  better  to  take  it  out  at  once. 

If  the  ball  has  penetrated  the  entire  thickness  of  the  skull  and 
lodged  within  the  cavity,  the  size  of  the  orifice  will  be  some  index  as  to 
its  probable  depth;  if  the  orifice  is  large,  it  argues  for  close  range  and 
deep  lodgment.  If  the  opening  is  small,  comparatively  speaking,  it 
is  likely  that  the  ball  has  not  penetrated  deeply.  Note  the  direction  of 
the  fissures.  If  the  base  is  involved  the  prognosis  is  always  serious. 
Note  the  condition  of  the  dura:  it  may  be  lacerated  and  the  brain  tissues 
may  exude.  If  such  is  the  case,  the  bullet  is  obviously  in  the  brain, 
but  its  exact  location  must  remain  a  matter  of  doubt.  It  is  not  ex- 
pedient to  explore  for  it;  it  is  not  even  advisable  to  attempt  to  disinfect 
the  cerebral  wound. 

It  is  sufficient  to  remove  all  fragments  of  bone  and  debris  and  wipe 
the  wound  dry  with  sterile  gauze.  On  these  two  points,  however, 
there  may  be  some  difference  of  opinion.  The  American  Text-book 
of  Surgery  insists  upon  the  value  of  disinfection  of  the  entire  cerebral 
track  of  the  bullet  and  of  through-and-through  drainage  under  certain 
circumstances;  also  upon  the  advisability  of  attempting  to  locate  the 
bullet  by  the  aluminum  gravity  probe,  and  to  remove  it.  Still  it  may 
be  said  that  the  general  practitioner  has  done  his  duty  and  done  it  well 
if  he  has  cleansed  the  skull  and  dural  wounds  and  controlled  the 


GUNSHOT    WOUNDS    OF   THE    SPINK. 


157 


lemorrhage.     (For  further  details  of  treatments,  see  Urgent  Craniei 

tomy.) 

GUNSHOT  WOUNDS  OF  THE  SPINE. 

A  man  was  brought  into  the  City  Hospital  shot  in  the  back  with  a 
H  revolver.  Except  that  he  was  paralyzed  from  his  hips  down  and 
without  control  of  his  bladder  and  bowels,  his  condition  was  good. 
This  positive  primary  paralysis  pointed  to  grave  injury  to  the  cord. 
At  the  operation  it  was  found  that  the  bullet  had  smashed  into  the 
spinal  canal  and  there  lodged,  completely  obliterating  in  its  course 


Fig.  108. — Complete  division  of  spinal  cord;  bullet  retained. 


a  considerable  segment  of  the  spinal  cord.  Suture  of  the  cord  was 
out  of  the  question,  so  the  poor  fellow — a  man  of  great  vitality — was 
condemned  to  linger  in  living  death  for  many  weeks. 

Happily  not  all  cases  of  gunshot  wound  involving  the  cord  are  be- 
yond relief.  Whenever  the  symptoms  point  to  severe  injury  of  the 
cord — whenever  there  are  notable  disturbances  of  sensation  and 
motion — and  improvement  fails  to  take  place  shortly,  it  is  bad  practice 
to  delay.     It  is  indicated  to  cut  down  upon  the  spine,  remove  a  spinous 


158  GUNSHOT    WOUNDS    IN    CIVIL   PRACTICE. 

process,  trephine  into  the  canal,  and  cautiously  cut  away  the  arches. 
It  may  develop  that  the  symptoms  are  due  merely  to  pressure  of  frag- 
ments of  bone  which  are  to  be  removed.  If  after  gunshot  wounds  of 
the  spine  there  are  no  cord  symptoms  or  if  they  are  mild  and  tend  to 
improve,  it  is  better  not  to  operate.  The  smaller  the  projectile  the  less 
the  likelihood  that  operation  will  be  required.  Without  some  positive 
indication  in  the  cord,  therefore,  aseptic  occlusion  is  the  treatment  to 
pursue.  Probing  is  all  the  more  perilous  because  infection  may  be 
carried  directly  to  the  spinal  meninges. 

GUNSHOT  WOUNDS  OF  THE  FACE. 

These  may  result  from  shots  into  the  mouth  with  suicidal  intent. 
Small  bullets  may  remain  imbedded  in  the  hard  palate  or  posterior 
pharyngeal  wall.  The  instinctive  tilting  of  the  head  backward  gives 
the  bullet  a  characteristic  course  through  the  hard  palate  or  the  root  of 
the  nose,  and,  owing  to  the  involvement  of  the  base  of  the  brain,  such 
wounds  are  deadly,  except  with  quite  small  fire-arms. 

In  other  cases  there  are  grave  comminuted  fractures  of  either  jaw. 
Sometimes  there  are  powder  burns  and  disintegrations  suggestive  of 
explosions. 

The  chief  dangers  in  cases  not  immediately  fatal  are  from  inter- 
ference with  respiration  and  from  hemorrhage.  These  wounds  are 
also  predisposed  to  infection,  and  as  a  result  of  sepsis  secondary 
hemorrhage  is  not  infrequent.  Paralysis  of  the  facial  nerve  may  occur. 
The  salivary  glands  or  their  ducts  may  be  injured  and  give  rise  to  a 
troublesome  dribbling  of  saliva.  Marked  interference  with  respira- 
tion may  call  for  immediate  tracheotomy. 

Arteries  may  need  to  be  ligated  and  ligation  may  be  difficult  owing 
to  their  relation  to  the  bones.  The  oozing,  always  marked,  is  to  be 
controlled  by  pressure.  The  natural  contour  is  to  be  restored  as  much 
as  possible  after  a  thorough  cleansing,  and  the  wound  cavities 
packed  with  iodoform  gauze. 

GUNSHOT  WOUNDS  OF  THE  THORAX. 

Gunshot  wounds  of  the  thorax  do  not  differ  from  other  wounds  in 
this  region  except  in  their  graver  prognosis.     (See  page  105,  Wounds  of 


BULLET    WOUNDS   OF   THE   ABDOMEN.  150. 

Thorax,  and  page  132,  Military  Practice.)  Sucb  as  involve  the  great 
lessels  ai  the  root  of  the  Lungs  and  most  of  those  which  involve  the 
heart  are  not  even  of  interest  from  a  standpoint  of  treatment  because 
so  rapidly  fatal  as  to  preclude  intervention. 

Such  wounds  as  are  not  obviously  fatal,  whet  her  they  involve  the  pleura 
and  lungs  or  the  pericardium  and  heart,  present  three  sources  of 
■anger:  hemorrhage,  asphyxia,  and  infection.  These  are  the  three 
conditions  which  determine  the  line  of  treatment,  and  which  have 
■ready  been  discussed  under  the  head  of  Wounds  of  the  Thorax. 

Aside  from  these  symptoms  of  urgency,  the  treatment  must  be  con- 
servative and  expectant — quite  different  from  gunshot  wounds  of  the 
abdomen. 

Begin  by  covering  the  wound  with  an  aseptic  compress  and  then 
carefully  disinfect  the  field.  Finally  cleanse  the  wound  itself  and  dress 
antiseptically.     Avoid  probing  or  other  explorations. 

Transportation  must  also  be  avoided,  for  there  can  be  no  doubt  that 
it  is  often  disastrous.  In  the  country,  where  ambulances  are  out  of 
the  question,  the  nearest  shelter  is  the  best. 

If  it  is  evident,  finally,  that  the  hemorrhage  is  increasing,  as  indicate!  1 
by  the  symptoms  and  physical  signs,  conservatism  is  no  longer  rational 
and  the  wounded  lung  should  be  exposed  and  the  tear  repaired. 

Kiitner,  of  Leipsic,  proposes  in  the  future  when  dealing  with  these 
wounds  to  evacuate  the  extravasated  blood  if  it  is  not  promptly  ab- 
sorbed, suturing  the  pleura  without  drainage.  In  the  case  of  an  al- 
ready collapsed  lung  it  does  not  appear  that  there  would  be  increased 
danger  operating  without  the  aid  of  a  Sauerbruch  cabinet. 


BULFFT  WOl/XDS  OF  THF  ABDOMFN. 


With  reference  to  prognosis  and  treatment,  these  wounds  fall  into 
three  clinical  groups:  those  which  are  obviously  penetrating  and  ac- 
companied by  grave  visceral  lesions;  those  which  are  doubtful  both 
as  to  penetration  and  visceral  injury;  and  those  which  are  probably 
benign. 

(A)  One  concludes  that  a  certain  wound  is  grave  no1  from  observing 
the  escape  of  gas  and  fecal  matter  or  hemorrhage  innn  the  wound, 


160  GUNSHOT   WOUNDS   IN   CIVIL   PRACTICE. 

for  these  are  too  infrequent  to  be  relied  upon,  but  from  the  general 
condition,  which  alone  is  of  sufficient  significance.  The  pulse  is  small 
and  rapid;  the  face  is  drawn  and  pale;  the  belly  wall  is  distended  and 
resistant  to  the  least  pressure;  dullness  of  the  iliac  fossa  and  flanks 
develops  and  there  may  be  vomiting  of  stomach  contents  or  of  blood. 

The  persistence  of  these  symptoms  for  the  first  two  or  three  hours  is 
sufficient  to  dispel  any  illusion  of  the  more  sanguine  that  the  case  is  not 
dangerous. 

There  is  but  one  thing  to  do,  operate  as  soon  as  possible. 

This  is  a  principle  so  definitely  established  that  the  citation  of  a 
long  list  of  eminent  authorities  is  unnecessary:  a  rational  doctrine 
that  all  may  accept. 

There  are  contingencies  of  time  and  place,  of  septic  environment 
which  would  insure  that  the  operation  itself  would  likely  be  fatal,  but 
those  conditions  are  very  exceptional  in  civil  practice  with  the  doctor 
who  has  the  "savoir-faire."  An  exceptional  condition  does  not  alter 
the  principle,  and  he  who  does  not  act  at  once,  must  incur  the  reproach 
of  having  refused  the  wounded  the  best  resource  of  safety. 

There  is  another  consideration.  One  may  not  be  called  to  see  the 
case  until  after  two  or  three  days  have  elapsed  and  may  then  encounter 
one  of  two  eventualities:  one  almost  certain,  the  other  unlikely. 

In  the  first,  there  are  the  signs  of  general  peritonitis.  Under  these 
circumstances,  again,  the  rule  is  to  operate,  though  only  as  a  forlorn 
hope. 

On  the  other  hand,  it  may  be  that  despite  the  apparent  gravity  of 
the  wounds,  the  pulse  is  good,  there  is  no  vomiting,  the  abdomen  is  not 
tender,  there  has  been  a  passage  of  flatus  or  a  movement  of  the  bowels. 
Although  we  know  these  appearances  are  often  deceitful,  that  it  may 
be  only  the  lull  which  precedes  the  storm,  yet  we  are  perfectly  justified, 
under  these  circumstances,  in  maintaining  an  "armed  expectancy." 
Under  such  circumstances,  control  peristalsis  with  a  little  morphia, 
impose  an  absolute  quiet  and  absence  of  food,  and  in  the  meantime 
have  the  patient  under  vigilant  surveillance. 

Fysche  reports  a  case  of  abdominal  gunshot  wound,  which  shows  the 
value  of  drainage  and  which  might  be  taken  as  an  indication  of  the 
course  to  pursue  in  certain  desperate  cases,  where,  for  example,  the 


LAPAROTOMY    FOR    BULLET    WOUNDS.  l6l 

circumstances  of  time  or  place,  the  condition  of  the  patient,  or  the  isola- 
tion and  lack  of  skill  of  the  operator  precluded  a  more  rational  and 
definite  pro<  edure. 

A  boy  of  fourteen  was  shot  through  the  abdomen  at  close  range  with 
a  large-caliber  revolver.  The  bullet  entered  just  to  the  inside  of  the 
right  anterior-superior  spine.  There  were  all  the  signs  of  shock  and 
internal  hemorrhage.  The  abdomen  was  opened  with  immediate  es- 
cape of  blood  and  fecal  matter.  The  first  portion  of  the  small  intestine 
examined  revealed  a  perforating  wound.  This  and  two  other  wounds 
were  repaired,  but  the  boy's  condition  called  for  haste  and  a  hurried 
examination  developed  seven  more  perforations  of  gut  and  mesentery 
along  the  six  feet  exposed.  The  abdominal  incision  was  closed  with 
through-and-through  sutures  with  a  large  deeply  placed  drainage 
,vick  in  the  lower  angle.  He  was  freely  stimulated  and  given  large 
enemas  of  normal  salt  solution.  The  drainage  was  removed  on  the 
second  day  and  from  the  opening  there  was  a  free  fecal  discharge.  On 
the  third  day  his  bowels  moved  naturally.  Thereafter  the  fistula 
closed  rapidly  and  in  a  month  he  seemed  quite  well.  (Montreal  Med. 
Jour.,  May,  1909.) 

(B)  The  case  is  one  of  doubtful  penetration  and  therefore  doubtful 
visceral  injury. 

you  are  called  immediately.  You  find  nothing  more  than  a  bullet 
wound  in  some  part  of  the  anterior  abdominal  wall.  The  pulse  is 
good,  the  abdomen  is  neither  rigid  nor  tender,  and  there  is  no  other  in- 
dication worth  noting. 

Now,  what  are  you  to  do?  Wait  several  hours  watching  for  some 
indication?  Hut  this  is  a  dangerous  formula,  subject  to  various  inter- 
pretations, for,  as  Lejars  asks,  what  shall  be  regarded  as  the  first 
"indication"-  the  weaker  pulse,  the  tympanites,  the  altered  fades? 
But  these  are  the  signs  of  beginning  peritonitis. 

It  is  better,  as  Brown,  of  St.  Louis,  and  many  others  have  so  defi- 
nitely determined,  to  answer  the  question  resolutely  in  these  terms: 
prepare  at  once  to  operate;  determine  whether  the  wound  is  a  penetrat- 
ing one  or  not,  ami  if  so,  proceed  with  the  laparotomy — provided,  of 
bourse,   that   the  situation   is  such   that  it  can   be  done   without    very 


1 62  GUNSHOT    WOUNDS    IN   CIVIL   PRACTICE. 

grave  danger  from  the  operation  itself.  It  may  develop  that  the 
operation  is  not  necessary,  but  it  will  very  much  more  frequently  be- 
come evident  that  it  is  indispensable. 

Admit  that  these  urgent  laparotomies  are  difficult,  that  they  strain 
every  resource  of  emergency  antisepsis  and  surgical  skill,  that  the  per- 
forations are  often  multiple,  that  one  never  knows  just  what  he  must 
meet.  Admit  that  some  recover  from  these  wounds  without  operation, 
but  are  we  authorized  by  that  to  expect  in  another  case  so  fortunate  a 
denouement  ?  Admit  that  the  patient  has  several  chances  of  recovery 
without  operation  perhaps,  but  let  us  remember  we  have  no  means  of 
calculating  such  chances  even  in  the  more  favorable  cases,  and  cer- 
tainly the  chance  of  an  exceptional  process  cannot  give  more  hope  than 
an  early,  regulated,  and  aseptic  intervention. 

It  is  prudence  which  commands  operation.  As  Lejars  says,  this 
seems  the  wisest  course: 

Prepare  for  a  laparotomy.  Begin  by  cleansing  the  field  of  operation 
and  then  the  wound,  which  is  enlarged,  cutting  from  above  downward, 
layer  by  layer.  If  the  peritoneum  is  found  uninjured,  repair  the  in- 
cision carefully,  first  trimming  the  devitalized  tissues  away;  under  these 
circumstances,  one  may  safely  prognosticate  a  recovery. 

If  you  find  the  peritoneum  perforated,  slightly  enlarge  that  wound 
also,  that  you  may  get  some  idea  as  to  the  conditions:  a  flow  of  blood, 
bile,  intestinal  contents,  or  urine  may  indicate  what  one  may  ex- 
pect. But  the  fact  alone  of  perforation  of  the  peritoneum  is  an 
indication  to  open  the  abdomen  in  the  middle  line — to  do  a  median 
laparotomy. 

The  median  incision  will  be  above  or  below  the  umbilicus,  depending 
upon  the  level  of  the  bullet  wound  (see  Laparotomy  for  Traumatism) . 

(C)  There  are,  finally,  as. Lejars  points  out,  certain  bullet  wounds 
which,  even  though  penetrating,  may  be  regarded  as  unlikely  to  have 
produced  serious  results.  These  are  such  as  are  produced  by  pistols 
in  which  the  bullet  is  quite  small  and  impelled  by  an  insignificant 
charge  of  powder,  so  that  its  force  is  practically  spent  in  traversing  the 
abdominal  wall. 

And  even  though  the  digestive  tube  should  be  wounded,  the  opening 


GUNSHOT    WOUNDS   01    THE   JOINTS.  163 

is  not  large  enough  for  the  contents  to  escape,  for  the  mucous  membrane 
acts  as  a  plug  and  repair  quickly  takes  pla<  e. 
In  such  a  rase,  there  being  no  doubt  as  to  the  facts,  it  is  perhaps 

wiser  not  to  operate,  but  to  treat  by  aseptic  occlusion.  Nevertheless 
it  is  the  part  of  prudence,  however  sanguine  of  the  outcome,  to  keep 
the  case  under  close  watch  for  some  days. 

GUNSHOT  WOUNDS  OF  THE  JOINTS. 

The  knee,  which  is  the  joint  most  frequently  wounded,  may  serve  as 
a  type.  Suppose  it  is  wounded  by  the  discharge  of  a  fowling-piece, 
a  not  uncommon  accident.  The  character  of  these  wounds  is  variable. 
It  may  be  that  only  a  few  shots  at  long  range  have  penetrated  the 
joint,  or  it  may  happen  that  the  whole  load  has  torn  its  way  into  the 
joint  structure.  But  whatever  the  condition,  no  active  intervention  is 
called  for  if  the  case  is  seen  at  once. 

Cover  the  wound  with  sterile  gauze,  provide  a  temporary  splint,  and 
supervise  the  transportation.  Once  provided  with  shelter,  proceed  to 
carry  out  a  methodical  cleansing  and  examination.  Cleanse  the  held 
first  and  then  the  wound  itself. 

If  the  wound  was  received  at  long  range  and  probably  only  a 
few  shots  have  penetrated  the  joint  cavity,  the  careful  cleansing, 
antiseptic  dressing,  and  subsequent  immobilization  will  be  all  that 
is  required  to  bring  about  an  uninterrupted  recovery  without  loss  of 
function. 

If  the  wound  was  received  at  close  range  and  the  joint  is  freely  pene- 
trated by  the  shot,  which  have  carried  in  shreds  of  clothing  and  other 
foreign  particles,  the  treatment  is  quite  different. 

Suppost-  the  joint  is  swollen,  dark  blood  oozes  out,  and  the  cavity  is 
exposed  through  lacerated  wounds:  in  such  a  case  conservatism  will 
not  cure.  Prepare  to  operate  immediately.  Open  the  joint  and  with 
hot  normal  salt  solution  freely  Hush  out  the  shot,  fragments  of  bone 
and  cartilage,  Mood  clots  and  other  debris.  Do  not  be  sparing  of  time 
and  patience.  Trim  away  the  lacerated  tissues.  If  satisfied  with 
the  cleansing,  suture  the  deeper  layers  over  the  joint  SO  as  to  close  it 

completely,  and  drain  only  the  superficial  wound;  otherwise,  drain  the 


104  GUNSHOT    WOUNDS   IN    CIVIL   PRACTICE. 

joint  cavity  as  well.  Apply  an  antiseptic  dressing  and  immobilize, 
and  expect  a  good  result. 

The  situation  is  again  different  if  the  case  has  been  treated  first  by  the 
uninstructed.  The  wound  is  seen  some  time  after  injury  and  found 
covered  with  dirty  cloths,  or  a  handkerchief,  the  worse  for  usage,  is 
stuffed  into  the  wound.  No  covering  at  all  is  always  better  than  any- 
thing less  clean  than  a  sterile  dressing. 

The  treatment  is  the  same  as  before — in  every  way  as  rigorous  and 
systematic — but  there  are  not  the  same  certainties  by  any  means  that 
it  will  head  off  sepsis.  You  cleanse,  drain,  immobilize,  and  watch. 
You  watch  for  beginning  infection,  which  for  that  matter  may  develop 
in  the  simpler  cases  if  the  cleansing  is  not  complete.  Fever,  pain, 
swelling  of  the  joint,  all  rapidly  increasing,  are  the  signs  of  beginning 
infection  and  suppuration  and  call  for  immediate  action.  It  is  in- 
dicated to  open  the  joint  and  drain.     (See  page  423,  Arthrotomy.) 

Bullet  wounds  produce  similar  lesions,  although  usually  they  are  of 
the  milder  type.  Hemarthrosis  indicates  injury  to  bone  as  well  as 
soft  parts.  Sometimes  these  wounds  occur  with  scarcely  any  injury  to 
the  joint  structure,  the  bullet  lodging  in  the  epiphysis.  In  the  milder 
cases,  wherever  the  bullet  may  be,  it  is  better  merely  to  cleanse  and 
immobilize,  and  at  a  later  date,  if  necessary,  the  ball  may  be  removed. 
If,  however,  the  hemarthrosis  is  voluminous,  it  is  better  to  open  the 
joint  at  once  and  clean  out  the  cavity  and,  by  a  happy  chance,  the 
bullet  may  be  found  and  extracted.  (See  also  gunshot  wounds  of 
joints  in  military  practice,  and  compound  dislocations.) 

GUNSHOT  WOUND  OF  HAND. 

A  pawnbroker,  examining  a  revolver  brought  in  for  a  loan  and  which 
was  supposed  not  to  be  loaded,  was  shot  through  the  hand.  The 
32  bullet  passed  between  the  heads  of  the  third  and  fourth  metacarpals, 
splintering  the  fourth  in  some  degree.  The  tissues  were  powder- 
stained  along  the  track  of  the  bullet  and  the  wound  bled  very  freely. 

The  wound  of  entrance  in  the  palm  was  jagged;  the  wound  of  exit 
smooth.  The  wounds  were  cleansed  and  a  slender  forceps  passed 
through  the  hand,  a  piece  of  gauze  attached  and  pulled  into  place  for 
through-and-through   drainage  by    withdrawing    the    forceps.     The 


Sli'i  km  h  i  \i     WOUNDS    FROM    FOWLING-PIECE.  [65 

bleeding  stopped,  but  later  began  again  soaking  the  bandages.  Syring- 
ing the  wound  with  peroxide  and  packing  with  gauze  served  to  check 
the  bleeding  for  a  few  hours.     This  intermittent  hemorrhage  persisted 

for  two  days. 

The  hand  was  soaked  twice  daily  for  a  half  hour  in  hot  normal  salt 
solution;  the  swelling  ami  pain  rapidly  subsided  and  after  three  or 
four  days  the  wound  began  to  heal  without  the  least  evidence  of  in- 
fection. The  ring  finger  was  stiff  and  painful  for  some  time,  but  under 
massage  and  passive  motion  gradually  regained  its  use. 

Injury  to  the  tendons  constitutes  one  of  the  chief  complications  of 
gunshot  wounds  of  the  hand.  Free  trimming  away  of  the  shattered 
tissues,  free  drainage  and  free  use  of  hot  normal  salt  solution  seem  best 
calculated  to  promote  repair  in  this  class  of  wounds. 

SU PERFICIAL  WOUNDS  FROM  FOWLING-PIECE. 

A  farm  hand,  charged  with  trespass,  was  brought  to  the  county 
jail  sorely  wounded.  Two  charges  of  bird-shot  had  caught  him  on  the 
fly  and  peppered  his  back,  buttocks,  and  the  posterior  surfaces  of  thigh 
and  calves.  Evading  his  pursuers,  aided  by  the  darkness,  he  had 
reached  his  cabin  exhausted  and,  without  changing  his  bloody  clothes, 
lay  thus  unattended  for  two  days,  when  he  was  discovered  and  arrested. 
By  this  time  infection  had  set  in.  His  buttocks  and  calves,  particu- 
larly, where  the  shot  were  thickest,  were  swollen  and  inflamed.  Many 
of  the  shot  had  carried  shreds  of  clothing  into  the  tissue:  each  was  a 
focus  of  suppuration;  none  had  penetrated  beyond  the  skin.  The 
whole  injured  area  was  cleansed,  first  with  soap  and  water,  and  then 
rubbed  vigorously  with  peroxide  of  hydrogen;  the  more  superficial  of 
the  shot  were  picked  out,  and  finally  the  inflamed  surfaces  were  smeared 
with  Reclus'  ointment  and  covered  with  sheets  of  gauze  held  in  place 
by  adhesive  strips.  The  relief  from  pain  was  great.  In  three  or  four 
daily  seances  the  shot  were  all  picked  out  and  the  inflammation  practi- 
cally gone. 


166  GUNSHOT    WOUNDS    IN   CIVIL   PRACTICE. 

WOUNDS  FROM  TOY  PISTOLS  AND  BLANK 
CARTRIDGES. 

Two  things  are  noteworthy  in  connection  with  these  wounds:  first, 
the  surprising  power  of  penetration  of  cartridges  supposed  to  be  harm- 
less; and,  second,  the  great  danger  of  a  tetanus  infection.  The  "wad" 
may  be  buried  put  of  sight  in  the  tissues,  it  may  entirely  perforate  the 
hand,  or  it  may  produce  a  superficial  laceration.  As  a  rule,  the  hemor- 
rhage is  insignificant,  which  may  in  a  measure  account  for  the  devel- 
opment of  infection,  since  bleeding  is  nature's  means  of  disinfection. 

These  wounds  often  present  the  appearance  of  punctured  wounds, 
which,  more  than  others,  are  likely  to  furnish  conditions  favorable  to 
the  growth  of  the  tetanus  bacillus. 

It  may  be  that  the  disposition  of  the  wad  is  such  that  the  wound  is  in 
a  manner  stopped  up,  so  that  oxygen  cannot  reach  the  recesses  where 
the  bacillus  finds  its  lodgment.  It  is  true  that  tetanus  develops  in  only 
a  small  percentage  of  cases,  but  one  can  never  foretell  positively  what 
such  a  wound  may  do. 

It  is  the  duty  of  every  doctor  to  warn  his  clientele  of  the  danger  of 
these  "Fourth  of  July"  injuries. 

Every  case  is  to  be  treated  as  if  lock-jaw  is  not  merely  a  remote 
possibility,  but  a  probability.  Free  cleansing  and  douching  with 
peroxide  of  hydrogen  is  indicated. 

Luckett  says  (American  Journal  of  Surgery,  July,  1906):  "These 
wounds  should  be  freely  incised,  particularly  if  not  seen  on  the  first 
day  of  the  injury,  and  thoroughly  curetted  with  a  small  sharp  spoon 
until  all  the  small  pieces  of  wad,  the  unburned  grains  of  powder,  and  all 
the  dirt  have  been  removed.  If  the  wad  has  entered  a  metacarpal 
space  a  counter-incision  must  be  made  for  through-and-through 
drainage.  Having  cleaned  the  wound  as  thoroughly  as  can  be  done 
mechanically,  we  now  resort  to  chemicals  and  irrigate  with  some  mild 
antiseptic.  After  next  drying  the  wound  thoroughly,  the  entire  cavity 
should  be  swabbed  out  with  one  of  the  following,  named  in  order  of 
choice: 

"  1.  Pure  carbolic  acid  followed  by  alcohol. 

"2.  Twenty  per  cent,  tincture  of  iodine  (made  by  dissolving  iodine 
crystals,  20  parts,  in  ether  and  alcohol,  each  50  parts). 


WOUNDS    FROM    Toy    PISTOLS.  107 

"3.   Plain  tincture  iodine. 

"The  wound  should  now  be  packed  with  moist  iodoform  gauze. 
A  wet  dressing  is  then  applied,  to  he  changed  daily.  Permission  should 
he  obtained  for  a  prophylactic  injection  of  antitetanir  serum.  Ten 
CC.  are  intra-musi  ularly  injected  in  the  buttocks  or  thigh,  under 
thorough  antiseptic  precautions." 

Antitetanic  powder  may  be  applied  to  the  wound,  as  advised  by 
Calmette.  Experiments  conducted  by  Joseph  McFarland,  of  Phila- 
delphia, corroborate  Calmette's  statements  as  to  the  prophylactic  value 
of  this  substance.  By  its  use  McFarland  was  able  to  protect  from  in- 
fe<  tion  animals  which  he  had  inoculated  with  the  tetanus  bacillus. 


CHAPTER  XIII. 
FRACTURES. 

Definitions. — A  fracture  is  a  solution  of  the  continuity  of  bone  due  to 
traumatism. 

A  simple  fracture  has  a  single  line  of  solution  and  there  is  no  lesion 
of  the  soft  parts. 

A  multiple  fracture  has  more  than  one  line  of  solution  of  continuity 
in  the  same  bone  or  several  bones. 

A  comminuted  fracture  has  so  many  lines  of  solution  running  into 
each  other  that  the  bone  is  in  fragments  or  splinters. 

A  complete  fracture  involves  the  whole  thickness  of  the  bone.  It 
may  be  transverse,  longitudinal,  oblique,  dentate  or  comminuted. 

In  an  incomplete  fracture,  the  line  of  solution  does  not  involve  the 
whole  thickness  or  extent  of  the  bone.  It  may  be  a  fissure,  "a  green 
stick,"  a  depression  or  a  separation  of  an  apophysis. 

A  subcutaneous  fracture  has  no  communication  with  the  surface. 

An  open  or  compound  fracture  has  a  communication  with  the  surface, 
has  an  accompanying  solution  of  continuity  of  the  skin  and  the  sub- 
jacent soft  parts. 

A  spontaneous  fracture  is  produced  by  an  insignificant  traumatism 
and  is  usually  pathological,  due  to  disease  of  the  bone. 

An  ununited  fracture  is  one  in  which  bony  union  has  not  occurred  at 
the  usual  time. 

Gunshot  fractures  are  those  produced  by  projectiles  (see  Gunshot 
Wounds). 

The  symptoms,  the  diagnosis,  the  prognosis  and  treatment  vary 
with  the  region  involved,  and  with  respect  to  these  factors  fractures 
may  be  divided  as  follows: 

Fractures  of  the  skull. 

Fractures  of  the  face. 

Fractures  of  the  spine. 

168 


DIAGNOSIS   01    l  R  A'   i  I  B I     \l     nil     BASE.  169 

Fra<  hires  of  the  thorax. 

I  r.h  lun-s  of  the  extremities. 

FRACTURES  OF  THE  SKULL. 

Fractures  of  the  skull  are  important  practically  only  from  the  point 
of  view  of  their  complications,  which  number  three;  infection,  hemor- 
rhage, and  injury  to  the  brain. 

In  a  given  case,  one  or  all  of  these  complications  are  possibilities, 
Although  for  the  development  of  each,  certain  combinations  of  circum- 
stances are  peculiarly  favorable. 

With  respect  to  these  variations,  fractures  of  the  skull  are  of  two 
classes:  fracture  of  the  base  and  fracture  of  the  vault.  Each  has  its 
special  symptomatology  and  prognosis,  though  the  one  may  merge  into 
the  other  and  the  clinical  picture  be  more  or  less  blurred. 

Either  may  be  fissured,  fragmented,  or  compound,  with  or  without 
depression.  /;/  cither  the  immediate  gravity  depends  upon  the  nature  and 
extent  of  the  injury  to  the  brain,  and  fractures  of  the  base  are  the  more 
serious,  merely  because  the  more  important  areas  of  the  brain  are  there. 

With  regard  to  the  remoter  consequences  also,  fractures  of  the  base 
are  less  favorable;  hemorrhage  and  its  resultant  compilations  are 
more  to  be  feared;  and  infection  is  a  more  certain  eventuality  owing  to 
the  communications  opened  up  between  the  cranial  cavity  on  the  one 
side  and  the  ear,  the  nose,  or  the  pharyngeal  region  on  the  other. 

The  symptoms  in  either  kind  of  fracture  are  such  as  arise  from  con- 
cussion, compression,  or  laceration  of  the  brain  and  are  general  or 
focal,  that  is  to  say,  emanating  from  certain  cerebral  areas. 

FRACTURES    OF    THE    BASE. 

Fractures  of  the  base  of  the  skull  are  more  frequently  indirect,  the 
force  being  transmitted  through  the  spinal  column  from  some  part 
of  the  vault  or  the  ramus  of  the  jaw;  occasionally  direct  by  a  thrust 
through  the  mouth,  a  blow  on  the  root  of  the  nose,  or  upon  the  mastoid 
process. 

Any  <>r  all  of  the  fossae  may  be  involved.  Fracture  through  the  mid- 
dle fossa  is  most  frequent,  and  the  most  serious  is  fracture  through  the 


170  FRACTURES. 

posterior  fossa.  These  fractures  are  usually  linear  because  the  force 
is  indirect  and  because  there  is  only  one  determinable  table  instead 
of  two,  as  in  the  vault. 

These  fractures  are  nearly  always  compound,  which  adds  to  the 
gravity  of  the  prognosis.  The  external  meatus,  the  nasal  cavities  and 
the  naso-pharynx  are  all  prolific  sources  of  meningeal  infection. 

The  diagnosis  is  usually  by  inference,  often  impossible.  There 
are  certain  symptoms  always  suggestive  of  fracture  at  the  base,  but  not 
to  be  relied  upon  exclusively. 

Ecchymosis  in  the  tissues  about  the  orbit,  or  hemorrhage  into  the 
sclerotic,  appearing  first  some  little  time  after  the  injury,  and  gradually 
progressive — fracture  through  the  anterior  fossa  suggests  itself.  Per- 
sistent bleeding  from  the  nose  following  head  injury  must  be  given  due 
consideration.  Bleeding  from  the  external  meatus,  copious  and  per- 
sistent, suggests  fracture  through  the  middle  fossa.  Late  ecchymosis 
over  the  mastoid  or  into  the  tissues  of  the  back  of  the  neck  suggests 
fracture  through  the  posterior  fossa.  The  discoloration  follows  the 
posterior  auricular  artery.  However,  these  hemorrhages  must  not  be 
mistaken  for  local  rupture  of  mucous  membrane  or  other  soft  parts  and 
their  absence  does  not  necessarily  mean  absence  of  fracture. 

The  bleeding,  if  intra-cranial,  may  come  from  rupture  of  the  middle 
meningeal,  or  the  internal  carotid,  or  the  sinuses.  Instead  of  the  bleed- 
ing, or  accompanying  it,  there  may  be  escape  of  cerebrospinal  fluid. 
Its  presence  is  pathognomonic  of  fracture  of  the  skull,  and  it  must  be 
distinguished  from  ordinary  serum  and  the  fluid  of  the  middle  ear 
by  these  characteristics:  the  flow  begins  at  once  and  continues  for 
several  hours;  the  quantity  is  considerable,  sometimes  a  tablespoonful 
in  fifteen  to  twenty  minutes;  the  flow  is  temporarily  increased  by  the 
increase  of  intra-cranial  pressure,  sneezing,  coughing,  and  vomiting; 
alkaline  in  reaction;  contains  only  a  trace  of  albumin  and  is  rich  in 
sodium  chloride. 

Useful  in  definite  diagnosis  are  the  paralyses  of  the  cranial  nerves. 
Recall  their  origin,  course,  and  functions.  The  facial,  optic,  and  tri- 
facial nerves  are  especially  likely  to  be  involved.  For  example,  the 
optic  nerve  will  be  involved  if  there  is  a  fissure  of  the  optic  canal. 
Vision  may  be  lost  totally  and  immediately;  even  though  total  at  first, 


ik  v<  TUBES   OP    tin     VAT  I  i  171 


me  blindness  may  gradually  pass  away.     It  will  be  impossible  for  some 

time  to  say  whether  the  recovery  will  In'  permanent.  Added  to  these 
nerve  symptoms,   bul    QOt    particularly   helpful    in   the  diagnosis  of 

fracture,  may  lie  those  of  concussion,  compression,  or  laceration.  All 
these  conditions  may  exist  with  or  without  fracture. 

The  treatment  has  two  ends  in  view,  the  prevention  of  further  irri- 
tation of  the  brain  and  the  prevention  of  infection. 

Keep  the  patient  absolutely  quiet  in  hed  with  the  head  elevated,  ap- 
ply ice-bags,  and  keep  the  bowels  open. 

Whenever  fracture  of  the  base  is  even  merely  suspected,  carefully 
wipe  out  the  external  meatus  and  pack  lightly  with  sterile  gauze.  Do 
not  syringe  the  meatus  or  at  least  only  very  gently,  lest  infection  be 
forced  through  the  fissure. 

Remove  the  gauze  as  often  as  it  becomes  soaked  with  blood,  which 
may  be  at  frequent  intervals  for  several  days.  Spray  the  nose  and 
throat  with  peroxide  of  hydrogen  or  a  similar  mild  antiseptic.  These 
regions  cannot  he  sterilized,  but  bacterial  activity  may  be  minimized. 
Do  not  pack  the  nares  except  for  persistent  nasal  hemorrhage,  as  the 
packing  irritates  the  mucosa  and  unduly  stimulates  secretion,  and  this 
is  undesirable.  Again,  such  packing  may  excite  a  sneeze  which  by  its 
explosive  effect  may  carry  infection  through  the  fissure  to  the 
meninges.  If  packing  is  deemed  necessary,  pack  with  sterile  gauze 
saturated  with  sterile  vaseline.  In  the  great  majority  of  cases,  active 
intervention  is  quite  out  of  the  question  either  for  the  relief  of  infection  or 
for  hemorrhage.  But  this  is  true  merely  because  the  technic  is  not 
definitely  worked  out.  The  principle  of  drainage  for  infection  and 
removal  of  compressing  clots  applies  with  as  much  force  here  as  in 
fractures  of  the  vault  (see  craniectomy). 

FRACTURF.S    OF    THE    VAULT. 

Fractures  of  the  vault  of  the  skull  may  he  fissured,  comminuted 
or  compound,  any  one  of  which  mav  he  complicated  by  concussion, 
compression,  contusion,  or  intracranial  hemorrhage.  The  symptoms 
belong  to  the  brain   complications   rather  than   to  the   fracture   itself. 

Simple,  fissured  fracture  without  depression  is  practically  impossible 


172  FRACTURES. 

of  diagnosis.  The  diagnosis  is  easier  if  depression  is  present  and  yet 
certain  injuries  to  the  scalp  simulate  fracture  with  depression.  A 
blow  crushes  the  soft  tissues  and  around  the  crushed  area  marked 
swelling  ensues.  The  sensation  to  the  examining  finger  is  that  of  a 
depression  of  the  bone.     Do  not  be  misled. 

Comminuted  fracture  of  the  skull  even  without  depression  is  gener- 
ally diagnosed,  and  yet  a  hematoma  may  mask  the   fragmentation. 

Be  on  your  guard  in  that  matter. 
^<^^^^^^^B^»  The    inner    table    is    always 

^ffy  lllillfe*  more     injured    than    the    outer 

_  ;    (Figs,  too,  no). 

*%  r  |||        The    prognosis    is   good    and 

the  treatment  simple  in  fissured 
fracture  without  depression  and 
without  symptoms  indicating 
compression. 

Put  the  patient  to  bed,  keep 

the  bowels  open,  limit  the  diet, 

and  await   developments.     Un- 

t  <^  f  interrupted      recovery     usually 

follows,    yet    the    exceptions   to 
this  rule  are  not  infrequent  and 
FlGi^lc7ST^4n1r?Ut^ai?°m      one  must  be  on  his  guard  for 

intra-cranial  hemorrhage.  Or 
later,  there  may  develop  symptoms  which  are  explainable  only  on  the 
hypothesis  of  contusion  of  the  brain. 

If  at  any  time  symptoms  arise  indicating  the  occurrence  of  hemor- 
rhage, say  from  a  ruptured  middle  meningeal,  immediate  intervention 
is  indicated.  Some  surgeons  go  so  far  as  to  recommend  trephining 
for  every  fracture  of  the  skull  and  exploratory  operation  in  every 
suspected  case,  but  that  seems  at  the  present  time  too  radical,  especially 
for  the  general  practitioner  left  to  his  own  resource. 

If  the  fracture  is  comminuted  or  even  only  fissured,  with  depression, 
the  chances  are  so  great  that  there  is  an  injury  to  the  brain  that  even 
with  no  symptoms  present,  immediate  operation  is  indicated.  (See 
Urgent  Craniectomy.) 


r.tMi'iM  M)    i  k\(  i  i  ri  s   01    THE    VAULT. 


173 


CUMI'iil    \1>    1  K  Mil   Kl  S    OF    Till.    \  All. I'. 


Much  more  serious  from  every  point  of  view  are  the  compound 
fractures  of  whatever  origin.  The  constant  element  of  danger  is  in- 
fection. Add  to  this  concussion,  contusion,  or  laceration  of  the  brain, 
and  the  outlook  is  grave  indeed.  The  treatment  is  not  so  simple,  hut 
its  purpose  is  quite  definite,  viz.: 
to  prevent  infection. 

This  is  accomplished  not  by 
keeping  the  streptococci  out  of 
the  wound — they  are  already  in; 
not  by  destroying  them  with 
strong  antiseptics,  as  these  are 
too  injurious  to  the  brain  tissues, 
but  rather  by  removing  the  con- 
ditions favorable  to  bacterial 
growth. 

To  this  end  operation  is  im- 
perative. As  in  gunshot  frac- 
tures, enlarge  the  wound,  re- 
move extraneous  matter,  elevate 
depressed  fragments,  check  the 
hemorrhage  and  remove  clots, 
trim  away  devitalized  tissues  and  provide  drainage  (see  Craniectomy). 
Careful  attention  to  these  details  results  in  the  starvation  of  the  germs 
present,  with  the  result  that  repair  proceeds. 

Skill  in  diagnosis,  prognosis,  and  treatment  in  fracture  of  the  skull 
depends  upon  a  clear  understanding  of  the  mode  of  causation  and  the 
tymptoms  of  contusion,  compression,  and  concussion  of  the  brain. 

Although  presenting  quite  a  diverse  clinical  picture,  separately  con- 
sidered, these  three  conditions  are  nevertheless  of  the  same  origin 
fundamentally.  They  are  each  merely  a  complex  of  symptoms  express- 
ing, on  the  one  hand,  varying  degrees  of  either  functional  depression 
or  stimulation  of  the  cortex  of  the  brain  or,  on  the  other,  of  the  deeper 
centers  of  the  cerebrum  and  medulla.  The  cortex  is  the  seat  of 
consciousness  and  at  the  same  time  the  most  sensitive  part  of  the  brain; 


Fig.    no. — Same;  fracture  inner  table.     Note 

greater  comminution  and  depression. 

(MouUin.) 


174  FRACTURES. 

therefore  it  is  the  first  to  be  affected  by  conditions  disturbing  the  circu- 
lation of  the  brain. 

The  deeper  centers,  those  governing  respiration  and  circulation,  are 
not  so  readily  affected.  The  result  is  that  loss  of  consciousness  is  the 
first  phenomenon  following  a  general  disturbance  of  traumatic  origin. 
This  trauma  may  not  be  sufficient  to  reach  the  cardiac  and  respiratory 
centers  at  first  or  at  all;  or  it  may  only  stimulate  them;  or  finally  it  may 
paralyze  them  as  well  as  the  cortex.  It  must  likewise  be  constantly 
remembered  that  stimulation  of  these  basal  centers  means  retardation 
of  pulse  and  respiration;  depression  of  the  same  centers  means  ac- 
celeration of  pulse  and  respiration,  and  acceleration  is  an  indication  of 
approaching  failure. 

It  is  only  by  reference  to  these  first  principles  that  one  may  explain 
and  reconcile  the  variations  in  the  derangements  of  these  functions  of 
consciousness,  circulation,  and  respiration  in  different  cases. 

CONCUSSION. 

This  is  in  all  probability  due  to  a  molecular  disturbance  of  the  brain 
substance,  and  is  accompanied  by  neither  microscopic  nor  macroscopic 
change.  The  disturbance  may  be  (a)  moderate,  (b)  severe,  or  (c) 
profound. 

(a)  The  disturbance  is  moderate.  Under  these  circumstances,  the 
trauma  depresses  the  cortex,  but  does  not  reach  the  deeper  centers 
of  the  brain  and  medulla,  so  there  is  therefore  only  a  fleeting  loss 
of  consciousness  without  any  change  whatever  in  the  pulse  and 
respiration. 

(b)  The  disturbance  is  severe.  The  force  depresses  the  cortex,  but 
only  serves  to  stimulate  the  deeper  centers,  and,  as  before,  there  is  loss 
of  consciousness,  but  there  is  this  time  slowing  of  pulse  and  breathing. 
Very  soon  the  normal  rate  returns  and  a  little  later  consciousness 
is  restored. 

(c)  The  disturbance  is  profound.  The  cortex  is  paralysed  and  pro- 
foundly depressed  as  are  also  the  deeper  centers.  The  result  is  loss  of 
consciousness  and  this  time  rapid  and  weak  pulse  and  shallow  breath- 
ing which  may  terminate  very  shortly  in  death.     In  doubtful  cases, 


l()N(   I  SSION.  175 


then,  the  heart  is  the  chief  elemenl  in  prognosis.     The  pulse  imme 
diaU'ly  grows  either  worse  or  better. 

Therefore  the  symptoms  of  concussion  arc  distinctly  fugacious. 
This  is  its  chief  criterion. 

If  the  symptoms  once  improve  and  later  recede,  one  may  be  sure  the 
primary  concussion  is  complicated  by  compression  or  contusion. 
Added  to  these  phenomena  of  concussion,  though  not  particularly 
helpful  in  diagnosis  or  prognosis,  are  certain  other  occasional  symp- 
toms, referable  to  the  reflexes. 

In  the  severe  cases  this  will  usually  be  the  picture:  At  the  moment 
of  injury,  unconsciousness  occurs,  immediate  and  complete.  The 
patient  is  more  than  unconscious,  he  is  anesthetized.  The  face  is  pale 
and  sunken  and  the  whole  body  cool.  The  pulse  is  small,  rapid,  and 
irregular.  The  temperature  is  subnormal.  The  breathing  is  shallow 
and  sometimes  sighing.  The  urine  and  feces  may  be  retained  or  pass 
involuntarily.  Repeated  vomiting  is  quite  common,  especially  as 
consciousness  begins  to  return.  Following  the  return  of  conscious- 
ness, a  stage  of  excitement  occurs.  The  symptoms  of  this  stage 
are  those  of  meningeal  irritation,  and  in  uncomplicated  cases  rapidly 
subside. 

The  treatment  is  quite  definite.  Disturb  the  patient  as  little  as 
possible  in  getting  him  into  bed.  Lower  the  head  at  first  and  try  to 
maintain  the  body  heat  with  woolen  blankets  and  hot-water  bottles. 
Carefully  stimulate  the  heart.  To  this  end,  apply  a  mustard  draft 
over  the  heart  and  inject  ether  hypodermically  or  a  10  per  cent,  solu- 
tion of  camphorated  oil.  Repeat  these  injections  frequently,  being 
guided  by  the  pulse.  Yon  Bergmann  recommends  inhalations  of 
ether  for  the  very  weak  and  failing  pulse. 

Do  not  forget  artificial  respiration.  In  those  severe  cases  where  the 
respiration  is  dangerously  low,  it  will  sometimes  tide  the  patient  over 
the  danger-line. 

In  the  subsequent  stage  of  congestion,  keep  the  head  elevated  and 
apply  ice-caps  if  the  dressings  will  permit.  Keep  the  bowels  open. 
If  the  excitement  and  restlessness  are  pronounced,  morphine  hypoder- 
mically  is  indicated  (Von  Bergmann). 


176  FRACTURES. 

COMPRESSION. 

Any  condition,  traumatic,  inflammatory,  or  neoplastic,  which  dimin- 
ishes brain  room,  may  induce  symptoms  of  compression  of  the  brain. 
The  symptoms  and  their  course  will  vary  according  to  the  manner  in 
which  the  pressure  is  produced. 

What  is  said  here  applies  particularly  to  the  pressure  symptoms  origi- 
nating in  depressed  fracture  or  traumatic  hemorrhage,  though  much 
would  apply  equally  well  to  the  pressure  of  brain  abscess  or  brain 
tumors,  or  meningeal  exudates  and  similar  conditions. 

Pressure  symptoms  have  fundamentally  the  same  origin  as  concus- 
sion symptoms,  that  is  to  say,  they  are  an  expression  of  depression  or 
of  stimulation  of  the  cortex  and  the  automatic  centers.  In  both  there 
may  be  initial  stimulation  and  terminal  paralysis.  However,  this 
depression  or  stimulation  is  produced  differently  in  the  two  conditions, 
concussion  and  compression. 

In  the  first  case,  the  disturbance  of  function  is  brought  about  by 
mechanical  injury  and  in  the  second  by  interference  with  the  blood 
supply.  Sudden  diminution  in  the  circulation  modifies  the  functional 
activity  of  the  brain  centers. 

The  cortex,  the  most  sensitive,  is  first  affected,  followed  by  loss  of 
consciousness.  The  automatic  centers  are  next  affected,  at  first 
stimulated,  though  each  reacts  differently;  thus  the  respiratory  center 
is  the  first  to  be  stimulated  and  by  the  presence  of  carbon  dioxide  which 
was  its  primal  stimulus.  The  vaso-motor  centers  are  next  invaded, 
and  finally  the  vagal  and  convulsive  centers. 

In  those  cases  where  the  circulation  becomes  gradually  slower, 
the  order  in  which  these  centers  and  areas  are  successively  affected  is  as 
follows:  the  cortex,  the  corona  radiata,  the  gray  matter  of  the  spinal 
cord,  the  pons,  and  finally  the  medulla.  Now  the  symptoms  origi- 
nating in  these  various  areas  as  a  result  of  pressure  are  of  two  kinds : 

(a)  General  or  indirect. 

(b)  Focal  or  direct. 

Each  may  manifest  itself  in  two  stages: 

(1)  Stage  of  stimulation. 

(2)  Stage  of  depression  or  paralysis. 


HI.I  I   MIW.     ]'K()\I    Till      MIDDL1      M I  NINGEAL.  177 

It  is  the  knowledge  of  these  Eat  ts  which  enables  us  t<>  harmonize  and 
reconcile  the  diverse  statements  of  various  observers  regarding  the 
character  and  cause  of  the  symptoms  of  compression.  It  is  in  the 
kemorrhage  arising  from  the  middle  meningeal  artery  that  the  emer- 
gency surgeon  is  chiefly  interested.  Traumatic  compression  suffi- 
ciently serious  to  require  immediate  operation  in  nine  cases  out  of  ten 
originates  in: 

BLEEDING  FROM  THE  MIDDLE  MENINGEAL 
ARTERY. 

This  may  follow  injury  to  the  head  with  or  without  fracture.  The 
fracture  may  or  may  not  be  diagnosed. 

In  a  typical  case  the  concussion  symptoms  which  supervened  im- 
mediately upon  the  injury  disappear  after  a  half-hour.  The  patient 
regains  consciousness,  and  the  pulse  and  respiration  approximate  the 
normal. 

In  the  meantime,  however,  the  blood  from  the  torn  meningeal  is 
slowly  oozing  into  the  space  between  the  dura  and  the  skull,  and  the 
"free  interval"  is  interrupted  by  headache,  irritability,  perhaps  delir- 
ium (stimulation  of  the  cortex).  The  epidural  clot  grows  larger,  the 
intracranial  circulation  is  more  impeded  and  complete  loss  of  conscious- 
ness occurs  (depression  of  the  cortex).  Coincident  with  this,  the  pulse 
grows  slower  and  stronger,  the  respiration  deep  and  stertorous  (stimu- 
lation of  automatic  centers).  A  little  later  coma  is  profound,  the 
respiration  begins  to  fail,  and  the  heart's  action  grows  rapid,  weak 
and  irregular  (depression  of  both  cortex  and  automatic  centers),  and 
finally  all  the  functions  of  the  entire  organ  are  suppressed  a nd  paralyzed, 
and  death  ends  the  scene. 

Along  with  these  general  symptoms  there  frequently  occur  at  various 
stages  certain  focal  symptoms,  monospasms,  convulsions;  monoplegia 
or  hemiplegia. 

I'sually  at  the  time  the  decision  to  operate  is  made,  this  will  be  the 
condition  of  the  patient:  He  lies  inert,  unconscious,  the  pulse  full 
and  bounding,  the  respiration  deep  and  stertorous,  the  skin  hot  and 
perspiring,  the  pupils  irregular,  usually  dilated  on  the  side  of  compres- 
sion, partial  or  complete  hemiplegia  of  the  opposite  side. 


178  FRACTURES. 

Treatment. — With  a  definite  diagnosis  once  made,  there  is  no  differ- 
ence of  opinion  as  to  the  treatment.  It  is  imperative  to  operate,  and 
to  do  so  without  delay.  Every  additional  hour  adds  to  the  certainty 
of  a  fatality.  The  nature  of  the  injury  and  the  focal  symptoms  point 
to  the  site  of  the  clot  or  the  branch  of  the  meningeal  most  probably 
involved. 

By  trephining,  the  clot  is  exposed,  and  removed,  and  the  bleeding 
vessel  discovered  and  ligated.     (See  Craniectomy.) 

The  pressure  symptoms  of  hemorrhage  from  injuries  of  the  sinuses 
are  identical  with  those  from  meningeal  bleeding  except  that  they 
develop  much  more  slowly  and  are  likely  not  to  be  so  typical.  Hemi- 
plegia is  not  always  in  the  side  opposite  the  clot. 

FRACTURES  OF  THE  VERTEBRA. 

Fractures  of  the  vertebra  derive  their  chief  importance  from  the 
accompanying  injury  to  the  spinal  cord  and  are  serious  in  proportion 
to  the  amount  of  injury  to  the  cord,  ligaments,  and  tendons. 

Aside  from  local  pain  and  deformity,  the  symptoms  are  such  as 
arise  from  compression  or  laceration  of  the  cord  and  vary  somewhat, 
depending  on  the  particular  portion  of  the  cord  involved.  Fractures 
of  the  cervical  vertebra  are  at  once  the  most  common  and  fatal.  Frac- 
tures in  the  lumbo-dorsal  region  occur  next  in  frequency.  The  break 
which  usually  involves  the  body  of  the  vertebra,  but  may  include  the 
lamina  or  transverse  or  spinous  processes,  is  generally  due  to  forced 
flexion.  Along  with  the  fracture  the  ligaments  are  lacerated,  the 
muscles  torn,  the  vertebra  displaced  and  the  blood  vessels  opened. 
There  may  be  present  paraplegia  and  disturbances  of  the  functions  of 
bowel  and  bladder;  and  in  addition  to  these  symptoms  there  are  certain 
others  which  are  common  to  fractures  of  the  vertebra  wherever  located, 
such  as  pain,  tenderness  to  pressure  and  motion.  Occasionally  one 
will  find  deviations  and  angular  deformities.     (Fig.  111.) 

The  prognosis  in  a  well-defined  case  is  always  bad,  although  by  no 
means  always  hopeless. 

The  emergency  treatment  is  limited  generally  to  transportation  and 
securing  the  proper  bedding.     The  patient  must  be  handled  with  the 


FRACTURE    OF    Till     V  I  R  rEBRA. 


'79 


greatest  care.     Sometimes  the  least  added  pressure  <>n  die  cord  by  the 
movements  of  the  spine  may  produce  immediate  death. 

Tlu-  bed  must  be  uniformly  soft  and  smooth.  A  water  bed  is  ideal. 
If  the  symptoms  of  compression 
are  urgent,  it  is  necessary  at 
once  to  make  an  effort  to  re- 
duce the  fracture  by  simulta- 
neous traction  and  pressure. 
While  the  assistants  pull  on  the 
head  and  feet,  the  doctor  at- 
tempts, by  pressure,  to  correct 
the  deformity.  There  is  some 
danger  of  a  fatal  asphyxia  where 
the  fracture  is  high,  in  making 
these  manipulations,  as  the 
patient  is  turned  on  his  face  and 
the  movements  of  the  diaphragm 
may  he  interfered  with.  Lami- 
nectomy is  not  to  be  considered 
when  the  indications  point  to 
complete   crushing  of  the  cord. 

In  other  cases  where  the  pressure  symptoms  are  obvious,  a  laminectomy 
should  be  done  without  delay.    (See  Wounds  of  the  Spine.) 


PlG.  iii. — Fracture  of  vertebra.      (Moullin.) 


FRACTURE  OF  THE  NASAL  BONK. 

Aside  from  gunshot  fractures  (see  page  144),  the  bones  of  the  face 
suffer  occasionally  from  direct  violence. 

The  nasal  bones  may  be  fractured  alone  or  in  connection  with  the 
ethmoid.  Bleeding  is  profuse  and  deformity  apparent.  On  account 
of  infection  from  either  the  outside  or  inside  of  the  nasal  cavity,  in- 
flammation and  necrosis  may  In-  a  sequela. 

Ad  attempt  should  be  made  at  once  to  elevate  the  depressed  frag- 
ments by  pressure  within  the  nasal  cavity.  The  reduction  may  be  both 
difficult  and  painful.     General  anesthesia  may  be  necessary. 

Check  the  hemorrhage  by  mopping  the  nasal  cavity  with  a  solution 


180  FRACTURES. 

of  adrenalin  chloride,  or  pack  temporarily  with  sterile  gauze.  Sub- 
sequently douche  the  nasal  cavity  frequently  with  glycothymoline  or 
Seiler's  solution  to  prevent  infection. 

FRACTURE  OF  THE  SUPERIOR  MAXILLA. 

Fracture  of  the  superior  maxilla  occurs  alone  or  with  fracture  of 
the  malar  or  other  bones  of  the  face.  It  may  be  accompanied  by 
splintering  of  the  bone,  caving  of  the  antrum,  loosening  of  the  teeth, 
and  disfigurement  generally.  The  alveolar  process  may  be  broken 
off.     If  this  is  the  case,  it  may  be  replaced  without  great  difficulty. 

Oftentimes  little  can  be  done  to  correct  the  deformity.  The  lower 
jaw  can  be  used  as  a  splint  and  very  little  force  is  needed  to  retain 
the  fragments  in  position. 

If  the  fracture  is  compound,  the  fragments  should  be  treated  con- 
servatively. It  is  surprising  how  perfectly  they  may  sometimes  be  re- 
paired.   The  vascularity  of  both  bone  and  periosteum  favors  this  result. 

With  the  jaw  at  rest,  a  liquid  diet  should  be  maintained  and  fre- 
quent cleansing  with  alkaline  antiseptic  fluids.  Be  on  guard  for  frac- 
ture of  the  base  of  the  skull. 

FRACTURE  OF  THE  MALAR  BONE. 

Fracture  of  the  malar  bone  seldom  follows  the  suture  lines.  The 
whole  bone  may  be  dislocated  in  a  direction  corresponding  to  the 
force.  In  this  manner,  the  injury  may  be  transmitted  to  the  superior 
maxillary,  its  sinus  and  infra-orbital  canal,  to  the  nose,  the  orbit,  and 
the  base  of  the  skull. 

Uncomplicated  fractures  of  the  malar  bones  require  little  treatment. 
Compounds  fractures  must  be  treated  on  general  principles. 

It  may  be  possible  to  replace  a  depressed  fracture  of  the  zygomatic 
process  by  pressure  through  the  mouth. 

FRACTURE  OF  THE  INFERIOR  MAXILLA. 

Fractures  of  the  inferior  maxilla  occur  most  frequently  just  in  front  of 
the  mental  foramen,  and  are  usually  compound,  opening  into  the  mouth. 

The  deformity  is  determined  chiefly  by  muscular  action  and  the 
degree  of  obliquity. 


Ik  \«   li  R]     in     I  III     LOWER    I  \\\ 


1S1 


The  diagnosis  is  rarely  difficult. 

Reduction,  which  is  indicated  by  a  correct  alignment  of  tin-  teeth, 
may  be  accomplished  by  bimanual  manipulation  with  the  fingers  of 

one  hand  in  the  mouth.  This  is  usually  easily  done,  the  chief  diffi- 
culty being  to  retain  the  fragments  in  position.  The  prevention  of 
infection  is  likewise  important.      (Fig.   112.) 

Oliver,  of  Indianapolis  (Ind.  Med. 
Journal,  1906),  has  described  the  mode 
of  treatment  most  applicable  in  the 
emergencies  of  general  practice.  He 
recommends,  as  the  result  of  his  ex- 
perience, that  in  the  ordinary  case, 
when  the  patient  retains  the  majority 
of  his  teeth,  the  upper  jaw  be  used  as 
a  splint. 

This  is  his  procedure:  before  attempt- 
ing reduction  and  without  anesthesia, 
if  possible,  he  begins  by  passing  a  loop 
of  wire  (soft  iron  wire,  gauge  26  or  28) 
around  the  neck  of  the  most  available 
tooth  behind  the  break  in  the  lower  jaw; 
a  similar  loop  is  thrown  around  the  cor- 
responding  tooth  in  the  upper  jaw.  Fl^e^^^^  ^^ 
Coming  forward  of  the  fracture  the  first 
solid  tooth  and  its  fellow  above  are  both  looped  in  the  same  manner. 

Next  a  similar  loop  is  adjusted  above  and  below  on  the  opposite 
side  of  the  jaw — on  the  sound  side.  Altogether  six  separate  wires 
have  been  used.  Bach  loop  is  now  twisted  down  tight  with  a  pair  of 
pliers,  so  that  the  teeth  are  firmly  encircled  and  the  free  ends  of  the 
wires  left  projecting  from  the  mouth  (Fig.  113). 

Reduce  the  fracture  as  the  next  step.  This  is  done  by  pressure  and 
traction  with  the  fingers  inside  and  outside  of  the  mouth. 

Immobilize. — This  is  accomplished  by  twisting  firmly  together  by 
means  of  the  pliers  the  corresponding  upper  and  lower  wires,  which 
brings  the  lower  jaw  into  intimate  contact  with  the  upper. 

Liquid  diet  sucked  through  the  teeth. 


l82 


FRACTURES. 


Antisepsis. — Direct  the  patient  to  fill  his  mouth  with  the  antiseptic 
fluid  and  to  churn  it  vigorously  backward  and  forth  between  the  teeth. 
This  washing  should  be  done  frequently  each  day,  and  especially  after 
each  feeding.  If  necessary,  as  additional  support,  a  plaster-of-Paris 
or  Barton's  bandage  may  be  applied. 


Fig.  113. — Wiring  the  teeth  for  fracture  of  the  lower  jaw.  Note  the  manner  in  which 
the  wires  encircle  the  upper  and  lower  teeth  before  and  behind  the  line  of  fracture.  The 
upper  wire  is  subsequently  twisted  with  its  corresponding  wire  below,  so  that  the  lower  jaw 
is  splinted  against  the  upper. 


The  wires  are  left  for  three  weeks,  or  longer  in  the  severe  cases, 
and  after  their  removal  a  bandage  should  be  kept  on  for  another  week. 
The  patient  should  be  supplied  with  a  small  pair  of  wire  cutters  and 
directed  how  to  use  them  in  an  emergency,  such  as  serious  vomiting 
which  might  result  in  asphyxia. 

As  Oliver  observes,  this  formula  may  be  varied  to  suit  the  individual 
case.     The  many  forms  of  splints  need  not  be  here  considered.     The 


FRACTURE    OF    Till.    CLAVICLE.  183 

cases  of  special  difficulty  in  reducing  and  retaining,  those  which  are 
compound  and  those  in  jaws  practically  edentulous,  require  wiring. 

This  is  an  operation  simple  in  theory,  but  more  difficult  in  practice. 

The  main  points  are  to  make  the  incision  along  the  lower  border  ot 
the  jaw,  cutting  to  the  hone  and  Letting  the  middle  of  the  incsion  fall 
over  the  line  of  fracture.  The  bone  is  carefully  denuded  of  perios- 
teum. The  sutures  are  not  to  come  in  contact  with  the  buccal  sur- 
faces. The  bones  are  drilled;  the  sutures  passed  and  tied,  the  peri- 
osteum drawn  over  the  sutures,  and  the  soft  parts  partially  repaired. 

FRACTURE  OF  THE  RIBS. 

Fractures  of  the  ribs  occur  most  frequently  between  the  fifth  and 
ninth,  and  are  usually  single  and  without  displacement.  If  the  vio- 
lence is  sufficient  to  break  a  number  of  the  ribs  simultaneously,  it  may 
cave  in  the  chest  wall;  and,  by  perforation  of  the  lung,  produce  emphy- 
sema, hemoptysis,  pneumothorax.  Pain  and  crepitus  point  to  the 
presence  of  fracture.  Detect  crepitus  by  laying  the  palm  over  the  site 
of  the  pain  or  by  the  stethoscope. 

Slight  displacements  may  be  reduced  by  making  pressure  over  the 
site  of  fracture  during  inspiration,  or  perhaps  by  compressing  the  chest 
from  front  to  back  between  the  two  hands.  Apply  adhesive  strips 
two  inches  wide  over  the  injured  side,  beginning  at  the  scapula,  and  fol- 
lowing the  course  of  the  ribs  around  to  the  sternum. 

Three  or  four  such  strips  may  be  necessary,  and  they  must  be  applied 
at  the  end  of  expiration. 

The  pain  will  almost  always  be  relieved  by  such  immobilization  of 
the  chest  wall.  Those  fractures  which  involve  the  viscera  are  consid- 
ered with  injuries  of  the  thorax. 

FRACTURE  OF  THE  CLAVICLE. 

Fractures  of  the  clavicle  formerly  occurred  more  frequently  than  any 
other,  but  are  not  now  so  frequent.  One-half  of  the  cases  are  in 
children.  The  break  very  much  more  often  occurs  in  the  middle  third. 
Occasionally  in  the  outer  third,  but  rarely  in  the  inner  third.      In  the 


1 84  FRACTURES. 

middle  third,  the  inner  fragment  overrides  the  outer,  the  result  of  the 
action  of  the  sterno-cleido-mastoid  and  the  muscles  that  pass  from  the 
thorax  to  the  humerus,  and  the  weight  of  the  shoulder  (Fig.  114). 

The  patient  leans  his  head  toward  the  injured  side  and  supports 
the  elbow,  the  position  of  greatest  comfort.  The  nature  of  the  accident, 
the  pain,  deformity,  crepitus,  and  mobility  determine  the  diagnosis. 

Reduction.— Seat  the  patient  on  a  low  stool;  direct  the  assistant  to 
stand  behind  and  to  grasp  the  patient's  shoulders,  steadying  the  sound 
one  with  one  hand  and  lifting  the  injured  one  upward,  backward,  and 


Fig.    114. — Fracture   of  clavicle.     Inner  fragment 
lifted  upward  by  sterno-mastoid.      (Moullin.) 


Fig.  115. — Velpeau's  bandage  for 
fractured  clavicle.      {Stewart.) 


outward.  At  the  same  time  the  operator  stands  in  front,  helping  move 
the  shoulder;  and,  by  pressure  and  manipulation  of  the  clavicle  between 
finger  and  thumb,  molds  the  broken  ends  into  place. 

The  reduction  is  complete  when  the  injured  shoulder  is  as  long  as 
the  sound  one,  measuring  each  from  the  sterno-clavicular  joint  to  the 
tip  of  the  acromion,  landmarks  which  can  always  be  defined.  Feel 
along  the  injured  clavicle  for  any  irregularities.  Apply  the  dressing. 
(1)  If  the  patient  is  to  be  kept  in  bed  for  other  reasons  than  the 
clavicular  fracture,  it  will  be  sufficient  to  keep  him  on  his  back  with 
a  small  pillow  between  his  shoulders  and  with  the  hand  lifted  to  the 
chest. 

(2)  Any  bandage  or  dressing  which  draws  the  shoulder  upward, 
outward,  and  backward,  and  holds  it  in  that  position  will  serve.     Of 


SAYKKS    DRKSSINC. 


185 


the  dressings,  a  number  arc  especially  recommended.     They  need  to 
be  applied  for  three  or  four  weeks  (Fig.  115). 

In  ordinary  practice,  the  Sayre's  dressing  is  excellent.  The  essen- 
tials are  two  adhesive  strips  three  inches  wide  and  long  enough  to  go 
once  and  a  half  about  the  body,  absorbent  cotton,  roller  bandages. 
Begin  by  fixing  the  end  of  one  adhesive  strip  loosely  about  the  injured 
ami  just  below  the  armpit.  The  loose  end  carried  around  the  body 
will  pass  over  the  lower  ends  of  the  scapuke.  Before  completing  the 
turn  about  the  lxxly,  place  layers  of  cotton  wherever  the  cutaneous 


Fir,.  116. — Sayre's   dressing.     Fig.  117. — Sayre's  dressing  com-   Fig.  118. — Anterior  view. 
First  stage.      (Moullin.)        pleted.  Posterior  view.  (.Uiiii/lm.)  (Moullin.) 


surfaces  are  to  be  in  contact.  The  turn  of  the  adhesive  strip  about 
the  body  is  completed.  This  holds  the  shoulder  in  the  backward  and 
outward  position  (Fig.  116).  The  hand  is  drawn  across  the  chest 
toward  the  sound  shoulder  and  the  second  adhesive  strip  is  applied. 
Fix  one  end  over  the  sound  shoulder  and  pass  it  across  the  back  to  the 
elbow  (Fig.  117).  It  covers  the  point  of  the  elbow  and  follows  the 
arm  across  the  chest  to  the  starting-point  (Fig.  118).  It  is  designed 
to  lift  the  shoulder  upward.  A  few  turns  of  roller  bandage  around  the 
chest  lend  additional  support  and  complete  the  dressing. 

Romer  describes  a   method  of  dressing  with  adhesive  strips  which 


1 86 


FRACTURES. 


does  not  require  the  arm  to  be  fixed  to  the  side  (Lancet,  London,  March 
31,  1909).  Three  strips  of  Z.  O.  plaster,  each  an  inch  and  a  half  in 
width,  should  be  applied  from  a  point  immediately  above  the  nipple 
over  the  clavicle  to  a  point  below  angle  of  the  scapula.  The  middle 
strip  should  cover  the  site  of  the  fracture  and  should  be  first  applied, 
the  lateral  ones  overlapping  it.     The  strips  should  be  firmly  applied 


Fig.  119. — Mayor's  sling.     First  stage.      (Lejars.) 


while  the  fragments  are  kept  in  apposition.  The  scapula  may  be 
steadied  by  a  strip  crossing  its  lower  ang'e  laterally.  The  arm  is  to 
be  carried  in  a  sling. 

Mayor's  sling  serves  an  excellent  purpose  here  as  well  as  in  certain 
injuries  to  the  arm.     It  is  applied  in  this  manner: 

Take  a  square  of  strong,  unbleached  muslin,  or  similar  material, 
large  enough  to  reach  easily  about  the  body;  fold  it  into  a  triangle. 


mayor's  sum;. 


187 


The  dhow  having  been  flexed  to  an  acute  angle  and  the  hand  carried 

toward  the  sound  shoulder,  the  handage  is  carried  across  the  flexed  arm 
and  around  the  chest,  its  upper  level  being  just  below  the  lever  of  the 
axilla  (Fig.  119).  The  two  points  are  fastened  behind  with  a  safety- 
pin  or  tied. 


PlG.  i-'o.  Mayor's  sling.  Second  stage. 
The  bandage  is  molded  snugly  to  the  arm. 
(Lejors.) 


Fig.  121. — Mayor's  sling  completed. 
1  Ltjars.) 


Now  turn  the  third  point  of  the  triangle  upward  between  the  flexed 
arm  and  the  body,  and  carry  it  up  <>vcr  the  shoulder  of  the  injure. I 
side  (Fig.  120).  Mold  the  bandage  well,  so  that  it  fits  and  supports 
the  forearm  snugly.  The  dressing  is  completed  by  hands  «  rossing 
over  the  shoulders  and  connecting  the  anterior  and  posterior  parts  of 
the  bandage  after  the  manner  of  suspenders  (Fig.  1  2  1 ). 


105  FRACTURES. 

FRACTURES  OF  THE  EXTREMITIES. 

Fractures  of  the  extremities  are  emergencies,  often  of  the  first- 
class;  their  reduction  sometimes  becomes  equivalent  to  a  major  opera- 
tion. But  it  cannot  be  said  that  these  cases  are  always  treated  well. 
As  Senn  says,  "Bad  results  following  fractures  have  been  the  tombstones 
that  have  marked  the  termination  of  an  otherwise  successful  profes- 
sional career  of  many  an  ill-fated,  unlucky,  disappointed  practitioner." 

Malpractice  suits  more  frequently  follow  this  class  of  cases,  perhaps, 
than  any  other,  which  is  an  indication  that  somewhere  there  is  a  fault. 
Doubtless  it  is  the  fear  of  a  damage  suit  that  often  makes  a  basis  for 
it  and  in  this  way:  The  doctor,  in  order  that  he  may  have  testimony 
as  to  his  skill,  treats  the  case  in  the  stereotyped,  and  routine  way; 
he  gets  a  bad  result.  Had  he  used  his  better  judgment,  given  his 
common  sense  rein  and  risked  the  reproach  of  being  an  innovator,  the 
result  would  have  been  different. 

Every  case  must  be  studied  and  treated  on  its  own  merits,  with 
due  regard,  of  course,  to  certain  general  principles.  To  begin  with, 
the  prognosis  should  always  be  guarded  in  some  degree.  As  King  says, 
(St.  Paul  Medical  Journal,  August,  1906):  "Optimism  as  to  the  final 
outcome  on  the  part  of  the  physician  is  a  mistake.  Take  the  patient 
into  your  confidence,  let  him  anticipate  the  certainty  of  some  permanent 
defect,  so  that  in  the  end  an  imperfect  result  will  not  reflect  so  much 
upon  your  skill  and  will  tend  to  minimize  malpractice  suits.  And 
how  very  rarely  indeed  can  the  result  be  perfect.  With  the  very  best 
treatment,  there  will  nearly  always  remain  as  the  best  outcome  some 
slight  weakness,  or  limitation  of  motion,  or  ache,  or  pain — at  least  a 
callus  as  a  'lasting  memorial.' " 

The  diagnosis  of  these  fractures  is  usually  easy  in  the  large  sense, 
as  King  says,  but  after  all  difficult  as  a  whole,  for  no  eye  can  see  the 
injury  wrought  to  the  softer  tissues.  In  many  cases  the  position  will 
indicate  at  once  that  there  is  a  fracture,  but  one  must  endeavor  to  learn 
much  more — the  possible  associated  injuries  to  joints,  muscles,  blood 
vessels,  and  nerves.  To  be  able  to  do  this  necessitates  a  fairly  accurate 
knowledge  of  anatomy  to  begin  with,  aided  by  systematic  examinations, 
and  on  this  foundation  skill  grows  with  experience. 


[)I  VC.NOSIS    (IF    I  K  VCT1    R]  S.  189 

The  diagnosis  of  fracture  in  the  bones  of  the  extremities  is  based 
on  several  fai  tors:  (a)  history  of  the  case,  (b)  deformity,  (c)  abnormal 
mobility,  (d)  pain  and  loss  of  function,  (e)  crepitus,  (f)  X-ray 
examination. 

(a)  It  is  essential  to  know  how  the  accident  occurred.  Frequently 
in  the  absence  of  definite  symptoms,  the  diagnosis  must  rest  upon  that. 
For  example,  in  a  case  of  a  hip-joint  injury  in  an  elderly  person  pre- 
senting loss  of  function  and  some  pain  but  no  other  symptoms,  a  diag- 
nosis of  impacted  fracture  should  be  made  if  it  is  learned  the  patient 
fell  striking  the  hip. 

(h)  Deformity  includes  changes  in  the  relations  or  dimensions  of 
the  hones  and  the  appearance  of  the  limb.  The  two  limhs  must  al- 
ways be  compared.  It  must  be  determined  that  there  has  been  no 
previous  injury  to  cause  the  deformity.  When  both  ends  of  a  bone 
are  accessible  to  touch,  it  may  be  readily  measured  and  compared  with 
its  opposite.  In  the  case  of  the  humerus,  it  is  necessary  to  measure 
from  the  acromion;  in  the  case  of  the  femur,  from  the  ilium.  The 
position  which  the  fragments  assume  may  be  due  to  the  direction  of 
the  force  or  the  action  of  the  muscles. 

(c)  Preternatural  mobility  implies  movement  in  unnatural  situations 
or  in  unnatural  degree  or  direction.  As  one  of  the  cardinal  signs  of 
fracture,  it  has  hitherto  been  assigned  too  much  importance.  Its 
presence  indicates  fracture,  but  its  absence  indicates  nothing.  We 
all  know  that  in  impacted  fracture,  there  is  no  abnormal  mobility. 
In  fractures  of  the  bones  of  the  tarsus  and  carpus,  in  epiphyseal  fracture, 
in  any  fracture  where  the  fragments  are  small  or  deeply  placed,  it 
may  he  impossible  to  discover  movement  without  a  manipulation 
which  may  be  distinctly  injurious.  In  the  case  of  fractures  near  joints, 
it  may  he  impossible  to  determine  whether  the  movement  is  in  the  joint 
or  near  it. 

The  fact  is  that  in  most  cases  where  abnormal  mobility  is  present, 
the  fracture  may  be  readily  diagnosed  without  reference  to  this  sign. 

(d)  Crepitus  is  the  almost  constant  accompaniment  of  abnormal 
mobility  and  is  the  grating  produced  by  the  friction  of  the  two  fragments. 
It  is  pathognomonic,  but  must  not  be  sought  for  too  vigorously.  It  is 
absent  in  impacted   fracture,   and  to  break   up  an  impacted  fracture, 


IQO  FRACTURES. 

testing  for  crepitus,  may  be  a  calamity.  Crepitus  may  sometimes  be 
heard  with  the  phonendoscope  and  not  with  the  ear. 

(e)  Pain  and  loss  of  function  go  together  since  the  pain  is  usually 
the  cause  of  the  loss  of  function.  Both  are  present  in  nearly  all  frac- 
tures, but  often  occur  in  as  great  degree  with  contusions. 

The  amount  of  pain  varies  with  the  location,  but  is  nearly  always 
aggravated  by  movements  or  pressure.  Taken  in  connection  with  the 
history  of  the  case,  it  is  a  valuable  diagnostic  aid.  The  presence  of 
pain  may  call  for  anesthesia  before  the  diagnosis  can  be  completed. 

Stimson  has  recently  emphasized  the  significance  of  pain  in  the  diag- 
nosis of  fracture,  and  indicated  the  manner  in  which  it  may  be  inter- 
preted. Crepitus  and  abnormal  mobility  are,  to  his  mind,  of  less  im- 
portance than  pain  as  a  diagnostic  aid  (J.  A.  M.  A.,  March  27,  1909). 

The  search  for  pain  in  all  doubtful  cases  should  be  systematic. 
Begin  first  with  local  pressure  over  the  suspected  area  with  the  tip  of 
the  finger  or  with  the  rubber  end  of  a  lead-pencil.  There  are  definite 
lines  of  tenderness  to  be  discovered  in  many  of  the  fractures  about 
joints.  For  example ;  in  Colles'  fracture  this  line  can  be  plainly  traced 
across  the  radius  just  above  the  wrist;  in  fracture  of  the  external 
condyle  of  the  humerus,  along  the  external  condylar  ridge  just  above 
the  elbow;  and  in  fracture  of  the  surgical  neck  of  the  humerus,  along 
the  front  or  outer  side  of  the  bone. 

Next  test  the  character  of  pain  elicited  by  cautious  movement  of  the 
limb.  Increased  muscular  tension  thus  produced  awakens  increased 
pain  at  the  site  of  the  fracture,  and  the  patient  may  be  able  to  indicate 
the  exact  location  of  the  lesion.  The  effort  on  the  part  of  the  patient 
to  produce  certain  movements  is  helpful. 

Finally,  indirect  pressure  may  be  employed;  thus,  in  transverse 
fracture  of  the  tibia,  pressure  upward  on  the  foot  exaggerates  the  pain 
markedly,  and  in  the  same  manner,  pressure  upward  at  the  elbow, 
may  assist  in  locating  the  fracture  in  the  shaft  of  the  humerus. 
Stimson  notes  the  important  exception,  that  in  the  case  of  fracture  of 
the  neck  of  the  femur  forcible  pressure  upward  often  fails  to  cause  pain. 

In  the  case  of  fracture  of  one  of  the  bones  of  the  forearm  or  leg, 
squeezing  the  two  bones  together  will  generally  help  the  patient  to 
locate  his  trouble. 


PRINCIPLES    OP    TREATMENT   <  >  I     FRA<   M  RES.  101 

(f)  The  X  ray  cannol  be  ordinarily  available  in  general  practice, 
although  of  the  greatest  assistance  in  cases  of  doubt.  Without  its  use 
many  fractures  in  the  region  of  joints  will  be  diagnosed  as  something 

else.  Bloodgood  particularly  emphasizes  its  value  (Progressive 
Medicine,  Dec.,  iooo),  believing  that  the  doctor  who  neglects  the  aid 
of  the  Rontgen  picture,  when  he  is  able  to  obtain  it,  will  have  much  to 
regret.  There  is  no  danger  that  its  employment  will  blunt  the  diag- 
nostic sense,  unless,  as  is  often  done  in  hospitals,  it  is  used  to  the  ex- 
clusion of  other  aids.  The  X-ray  has  at  least  modified  our  notions 
as  to  what  constitutes  a  perfect  result  in  the  treatment  of  a  fracture. 
Wherever  the  X-ray  picture  is  used  to  back  up  a  claim  of  malpractice 
by  reason  of  inaccurate  apposition  of  fractured  bone,  we  must  insist 
that  restoration  of  form  and  function  constitutes  a  perfect  result 
surgically,  whatever  discrepancies  the  Rontgen  picture  may  reveal. 

The  trkatmknt  implies  a  reposition  and  an  immobilization  that  the 
bones  may  unite  in  their  normal  relations.  It  has  that  objective,  but 
has  also  another  which  is  not  necessarily  a  concomitant  of  the  first. 
The  bones  must  unite  without  deformity  but  there  also  must  be  res- 
toration of  the  limb's  functions.  Union  in  good  position,  then,  is  only 
one  of  the  means  to  a  larger  end.  It  is  better  to  say  that  the  treat- 
ment  includes  reduction,  immobilization,  and  mobilization. 

In  making  reduction,  violence  must  be  avoided.  Gentle  but  per- 
sistent effort  is  always  better  than  rude  haste  in  overcoming  the  re- 
sistance of  muscles  and  ligaments,  which  is  usually  the  chief  obstacle 
to  reposition.  The  line  of  traction  must  be  adapted  to  the  muscular 
action.  Traction  must  usually  be  accompanied  by  COuntertractioD 
and  local  manipulation  of  the  broken  ends. 

In  making  traction  it  should  be  made  directly,  if  possible,  on  the 
bone  involved,  without  the  intervention  of  a  joint.  For  example,  in 
reducing  the  humerus  the  traction  should  be  applied  above  the  elbow- 
joint.  Often  an  anesthesia  is  necessary  to  relax  the  muscles,  and  if 
anesthesia  was  necessary  to  complete  the  diagnosis,  everything  should 
have  been  prepared  previously  for  the  treatment  so  that  only  a  single 
anesthesia  is  necessary  for  diagnosis,  reduction,  and  dressing. 

In  the  cases  of  suspected  fracture  in  the  vicinity  of  a  joint,  it  is  not 
always  best   to  hurry  the  reduction;  often   it   is  better  to  wail  a  day 


192  FRACTURES. 

or  so  and  try  to  reduce  the  swelling,  for  the  swelling  aggravates  the 
difficulties  which  are  always  great  in  the  differential  diagnosis  about 
the  joint;  and,  if  flexion  is  required,  as  in  the  case  of  certain  fractures 
about  the  elbow,  the  pressure  may  shut  off  the  circulation. 

So  far  as  the  shaft  of  the  long  bones  are  concerned,  however,  the 
formula  should  be  immediate  reduction  and.  fixation.  That  the  reduc- 
tion has  been  complete  is  attested  by  the  appearances  of  the  limb,  by  the 
absence  of  any  irregularities  to  the  touch,  and  by  the  coincidence  of  its 
measurements  with  those  of  the  sound  limb.  These  comparative 
measurements  should  be  a  matter  of  routine  practice. 

Warbasse  says  (J.  A.  M.  A.,  March  13,  1909),  "  the  sooner  a  fracture 
is  reduced  and  held  immovable,  the  less  will  be  the  swelling  and  the 
more  satisfactory  the  result.  There  is  a  prevalent  notion  of  waiting 
until  the  'traumatic  reaction  has  subsided.'  This  ancient  phrase 
rolls  off  the  tongue  sonorously  and  sounds  important,  but  is  to  be  rever- 
ently laid  aside.  Traumatic  reaction  is  going  on  all  the  time  as  long 
as  the  bones  are  out  of  place  or  so  long  as  they  are  movable.  If  we 
can  effect  immobilization  soon  enough,  the  swelling  will  not  come  up." 
This  is  doubtless  true  in  most  cases,  yet  it  is  too  be  remembered  that 
in  spite  of  reduction  of  the  bones,  lacerated  muscles  and  ruptured 
vessels  may  continue  for  some  time,  in  some  cases,  to  pour  their  exudate 
into  the  tissues  to  augment  the  swelling.  This  idea,  however,  pertains 
more  to  the  mode  of  dressing  and  does  not  refute  the  doctrine  of 
immediate  reduction. 

Immobilization  is  a  phase  of  treatment  raising  many  questions 
in  dispute.  In  what  manner  shall  it  be  applied  and  for  how  long? 
Or,  as  Championmere  insists,  may  it  not  in  many  cases  be  dispensed 
with  entirely  ?  For  he  believes  that  absolute  fixation  of  the  fragments 
is  not  the  condition  most  favorable  to  the  processes  of  repair.  A 
certain  amount  of  movement  is  necessary  to  the  vitality  of  the  bone, 
and  therefore  movements  and  massage  represent  the  chief  elements  of 
his  treatment.  That  it  is  the  best  treatment  for  fractures  about 
joints  no  one  will  deny,  even  though  unwilling  to  dispense  with 
fixation  in  other  fractures  of  the  long  bones. 

As  to  the  manner  in  which  fixation  is  to  be  attained,  let  it  be  said 
briefly  that  the  simplest  effective  dressing  is  the  best.     Its  elaborateness 


i  SI     OB   sim  i\  is.  tg  j 

will  depend  upon  the  tendency  for  the  displacement  i<>  recur,  and  this 
tendency  must  be  measured  by  the  degree  of  obliquity  of  the  fracture 

and  the  action  of  the  must  Irs.  Sometimes  the  temleiu  \  to  re<  urreni  e 
is  an  indication  of  imperfect  coaptation.  In  one  case,  then,  only  a 
light  retaining  splint  is  necessary  and  in  another  it  must  indeed  be 
firm  and  strong. 

At  the  present  time  there  can  be  no  question  but  that  plaster  of  Paris 
is  the  dressing  of  choice.      At  any  rale,  it  will   render  the  best  Service 

to  the  general  practitioner  who  must  rely  on  his  own  resources  in  fash- 
ioning splints.  Ready-made  splints  are  an  abomination.  There  are 
other  plastic  materials  that  are  often  useful,  and  in  lieu  of  all  these 
materials  the  splint  may  he  cut  into  forms  to  suit  the  case  from  hoards, 
etc.,  and  applied  well  padded.      (See  page  45.) 

Walsham  formulates  the  principles  which  must  regulate  the  use  of 
splints  in  any  case. 

1.  The  splints  must  he  well  padded. 

2.  Pressure  must  not  he  made  over  the  points  of  bones. 

_:;.   Strapping  or  bandages  must  not  be  put  on  too  tightly. 

4.  Circular  constriction  of  the  limb  must  be  avoided. 

5.  The  splints,  if  possible,  should  reach  beyond  the  joint  above  and 

below  the  fracture. 

6.  The  patient  should  be  seen  within  twenty-four  hours  after  the 

splint  is  applied  for  the  bandage  may  become  too  tight. 

7.  The  splints  should   not   be  needlessly  disturbed — that  is  to  say, 

If  the  patient  is  comfortable  and  the  limb  in  good  condition. 

8.  Spasm  of  the  muscles  is  to  be  overcome  by  Steady  extension. 

9.  The    part    below    the    fracture  should    be   bandaged,   or   at    least 

raised,   to  prevent  swelling  and  edema. 

The  first  immobilization  will  continue  till  there  is  no  tendency  to 
spontaneous  recurrence  of  the  displacement,  which  will  vary  in  differ- 
ent cases.  After  this  time  a  dressing  must  In'  used  which  i-;  easily 
(hanged,  and  daily  massage  must  be  instituted.  Complete  and  con- 
tinuous fixation  through  a  long  period  is  distinctly  bad  practice  and 
most  especially  whenever  a  joint  is  involved. 

Rossi    has   shown    (Wiener    Medical    Presse,    Jan.,    u)02)    that    the 

amount  of  new  cartilage  formation  is  proportional  to  the  amount  of 


IQ4  FRACTURES. 

movement  permitted  and  is  found  in  the  greatest  amount  in  fractures 
treated  by  massage,  and  is  explained  by  the  greater  formation  of  new 
blood  vessels  and  the  consequent  more  active  circulation  and  absorp- 
tion of  effusion. 

First  aid  to  those  disabled  with  fractured  limbs  is  in  civil  practice 
more  frequently  given  by  others  than  the  doctor.  It  is  desirable,  how- 
ever, whenever  possible,  that  he  should  direct  the  transportation  and 
the  preliminary  treatment. 

The  utmost  care  must  be  practised  in  liftmg  and  handling  the  broken 
limb,  lest  the  injuries  be  augmented  and  a  simple  fracture  converted 
into  a  compound. 

If  fracture  is  merely  suspected,  it  must  be  assumed  to  be  present. 
The  limb  must  never  be  lifted  by  the  foot  or  hand  but  must  be  lifted 
as  a  whole,  resting  upon  the  palms  of  the  hand.  Two  attendants  are 
always  better  than  one  in  handling  a  broken  leg.  If  the  deformity 
is  quite  obvious  even  to  the  unpractised,  an  effort  should  be  made 
toward  reduction  before  applying  temporary  splints,  this  with  a  view 
to  preventing  further  injury  to  the  soft  parts. 

The  limb  is  seized  by  an  attendant  at  each  end  and  gentle  and 
steady  traction  made  in  the  direction  of  its  axis.  If  this  does  not 
succeed,  the  attendants  must  not  persist  in  the  effort.  It  must  be 
left  for  the  surgeon. 

If  the  fracture  is  compound,  with  severe  hemorrhage,  the  clothing 
must  be  removed.  Otherwise  this  is  not  necessary.  In  removing 
the  trousers  or  a  coat,  for  example,  the  sound  limb  is  uncovered  first 
and  then,  very  gently,  the  injured  one.  It  is  better  to  cut  the  clothing 
or  rip  along  a  seam. 

A  splint  is  next  improvised  from  whatever  may  be  first  at  hand,  a 
thin  board,  laths,  an  umbrella,  or  the  branch  of  a  tree.  The  splint  is 
padded,  or  the  limb  wrapped  with  whatever  presents  itself,  a  blanket 
or  anything  to  prevent  undue  pressure,  and  then  is  fastened  on  the 
limb  by  a  cord,  or  belt,  or  suspenders,  etc.,  and  finally  the  injured  leg 
is  bound  to  the  sound  leg,  the  injured  arm  to  the  side  of  the  chest  or 
carried  in  a  sling. 

The  limb  thus  temporarily  immobilized,  the  patient  is  ready  to  be 
moved. 


FSACTTJR]    "i     i  in     -ii  \i  1    OP    mi     nrui  RUS.  [95 

To  lift  the  patient  with  the  greatest  safety  in  the  case  of  a  broken  leg, 
for  example,  one  attendant  standing  on  the  sound  side,  places  his  arms 
under  the  body  of  the  patient,  who  In  the  meantime  locks  his  arms 
about  the  attendant's  neck.  A  second  attendant,  standing  on  the 
same  side,  places  one  hand  under  the  body,  one  under  the  sound  liml>, 
while  a  third  attendant,  facing  the  others,  supports  the  broken  limb. 
At   his  word  of  command,  all  lift.     This  carefulness  must  not  be 

relaxed. 

[f  a  litter  is  available,  or  one  can  be  improvised,  it  is  plated  parallel 
with  the  patient,  its  feet  at  his  head,  so  that  without  any  inconvenience 
the  patient  may  be  laid  upon  it. 

FRACTURES  OF  THE  HUMERUS. 

Certain  points  of  anatomy  apply  to  nearly  all  fractures  of  the  arm, 
and  are  useful  in  diagnosis  and  reduction.  Recall  the  relations  of 
the  humeral  head  to  the  acromial  and  coracoid  processes;  the  great 
tuberosity;  the  internal  and  external  condyles;  the  attachments  of 
several  muscles,  particularly  the  deltoid,  biceps,  and  triceps;  the 
relations  of  the  musculo-spiral  nerve.  Remember  that  in  the  normal 
relations  a  line  dropped  from  the  tip  of  the  acromion  to  the  external 
condyle  will  touch  the  greater  tuberosity.  The  symptoms  and  treat- 
ment vary  somewhat  with  the  part  of  the  humerus  involved. 

Fracture  of  the  Shaft  of  the  Humerus. — Above  the  attachment  of  the 
deltoid  there  is  not  likely  to  be  much  deformity;  below,  the  deformity 
will  depend  upon  the  degree  of  obliquity.  Usually  the  displacement 
is  not  great.     Pressure  upward  at  the  elbow  will  elicit  pain. 

Reduction. — Seat  the  patient;  the  assistant  standing  on  a  chair 
lifts  the  shoulder  with  a  towel  passed  under  the  axilla.  Now  flex  the 
forearm  at  a  right  angle,  holding  ;t  with  one  hand  and  the  arm  just 
above  the  elbow  with  the  other.  Make  traction  on  the  arm  in  the 
direction  of  the  axis,  gently  rotating  to  disengage  the  fragments.  It 
is  a  good  indication,  if  there  is  much  grating,  that  none  of  the  soft 
parts  are  engaged. 

Reduction  is  complete  when  the  acromion,  tuberosity,  and  external 
condyle  are  in  the  same  line  and  the  injured  arm  the  same  length  as  the 


196 


FRACTURES. 


Fig.    122. — Testing  the  humerus  for  shortening.     Measuring  from   the  acromion   to   the 

external  condyle. 


in  nm  (.tin's   DRESSING. 


197 


other.  (Fig.  122.)  If  slight  rotation  is  particularly  painful,  think  of 
an  inclusion  of  the  musculo  spiral.  If  such  a  diagnosis  is  made,  it  will 
lie  necessary  to  operate.  A  general  anesthesia  may  be  necessary  to 
facilitate  reduction.  It  will  not  alter  the  principle  of  procedure.  The 
great  difficulty  is  to  maintain  the 
reduction  exact  until  the  dressing 
has  been  applied. 

With  the  idea  of  insuring  main- 
tenance of  coaptation  while  the  fixa- 
tion splint  is  benig  adjusted,  Lejars 
very  highly  recommends  the  appli- 
ance of  Hennequin.  It  is  equally 
applicable  in  some  of  the  other 
fractures  of  the  humerus,  and  is  em- 
ployed in  this  manner  (Fig.  123): 

The  patient  is  seated;  bandage 
the  injured  member  from  the  wrist 
to  about  three  inches  above  the 
elbow;  protect  the  axilla  with  ab- 
sorbent cotton;  flex  the  forearm  at 
a  right  angle  and  maintain  in  that 
position  in  a  sling.  Pass  a  band 
under  the  axilla  and  fasten  it  to 
something  (a  hook  in  the  wall),  so 
that  the  shoulder  is  slightly  lifted. 
That  is  the  counter-extension. 

Another  band  crosses  the  forearm 
just  below  the  bend  of  the  elbow 
and  to  it  is  attached  a  weight,  say 
of   2   K.   G.;   that  is  the  extension. 

Give  the  apparatus  a  little  time  and  it  will  effect  a  reduction  as  the 
muscles  tire.     Employ  this  interval  to  prepare  the  fixation  dressing. 

Cut  out  sixteen  strips  of  crinoline,  each  about  one  yard  long,  and 
wide  enough  to  cover  the  arm  at  its  thickest  part.  Lay  these  strips 
one  upon  the  other,  and  fasten  them  together;  and  from  the  sheet  thus 
formed,  cut  a  deep  scallop  out  of  either  end — at  the  lower  end  45  to 


Method  of  securing  extension  and  counter- 
extension  and  also  fixation  till  plaster  is 
applied.     {Lejars.) 


198  fractures. 

50  cm.  and  at  the  upper  end  15  to  20  cm.  deep.  Of  the  yokes  thus 
formed,  one  will  fit  into  the  axilla  and  the  other  into  the  bend  of  the 
elbow,  while  the  intermediate  portion  forms  an  internal  splint  for  the 
arm. 

Soak  the  cloth  in  liquid  plaster  and  apply  it  in  the  manner  indicated, 
molding  it  carefully  to  the  arm.  The  two  upper  bands  overlap  the 
shoulder  and  the  two  lower  ones  are  wound  spirally  around  the  arm 
to  the  wrist.  In  this  way  the  shoulder  and  wrist  are  immobilized.  In 
the  meantime  the  extension  and  counter-extension  are  not  disturbed 
until  the  plaster  split  is  fully  hardened.  The  dressing  may  be  further 
secured  by  a  few  turns  about  the  chest. 

Other  dressings  recommended  are  the  plaster  roller  from  the  wrist 
to  shoulder;  an  internal  splint  with  a  shoulder  cap  and  sling;  or  molded 
splints. 

Union  requires  from  six  to  eight  weeks;  failure  to  unite  is  usually 
due  to  the  interposition  of  the  soft  parts.  The  importance  of  the 
musculo-spiral  nerve  in  this  connection  must  never  be  forgotten. 

Fracture  of  the  Upper  End  of  the  Humerus. — These  injuries  often 
offer  the  very  greatest  difficulties  in  diagnosis.  Such  cases  for  the 
most  part  present  themselves  with  swollen,  painful,  and  contused 
shoulders,  perhaps  deformed,  and  functionless.  You  ask  yourself: 
is  it  only  a  severely  bruised  joint;  is  it  a  dislocation  or  a  fracture  of 
the  surgical  neck,  or  perhaps  both;  or  is  it  an  impacted  fracture  of  the 
anatomical  neck;  are  the  soft  parts  implicated? 

Do  not  waste  time  in  vague  palpations  but  proceed  at  once  to  a 
systematic  examination,  under  chloroform,  if  necessary.  Begin  by 
locating  the  apex  of  the  acromion;  if  there  is  no  depression  beneath 
it;  if  the  thumb  cannot  be  pushed  into  a  concavity  but  comes  in  contact 
as  it  should  with  the  humeral  head,  you  may  conclude  there  is  no  dis- 
location. With  the  thumb  still  in  front,  close  the  fingers  on  the  poste- 
rior aspect  of  the  head  of  the  humerus,  and  with  it  thus  held  firmly, 
attempt  rotation  of  the  arm.  The  humeral  head  rotates  with  diffi- 
culty in  dislocation;  it  does  not  rotate  at  all  if  there  is  fracture,  and 
besides,  there  is  crepitation  (Figs.  124,  125). 

A  source  of  error:  If  the  lower  fragment  overrides  much,  its  rota- 
tion might  be  felt  and  mistaken  for  the  humeral  head.     Abduct  the 


DIAGNOSIS   <>|     PRACTURI     M    SHOULDER. 


199 


arm;  easily  done  in  fracture,  with  increase  of  deformity  and  pain. 
Pain  is  also  produced  by  pressure  upward  at  elbow  and  by  local 
pressure  over  the  front  and  outer  side  of  humerus. 


Pig.  124. — Examining  the  shoulder.     Rotating  head  of  humerus. 

Examine  the  axillary  spare  and  all  the  other  aspects  of  the  shoulder, 

comparing  the  two  sides;  and  compare  the  other  landmarks  of  the  arm. 


200  FRACTURES. 

Do  not  begin  any  treatment  until  the  diagnosis  is  assured.  How  unfor- 
tunate it  is  to  attempt  reduction  of  a  supposed  dislocation  by  the  ordi- 
nary method  when  it  is  complicated  by  fracture;  or  to  treat  as  a  con- 
tusion, a  fracture  with  displacement! 

To  consider  briefly  the  more  common  findings  of  such  examinations: 
i.  Fracture  of  the  surgical  neck  without  overriding  (Fig.  126)  needs 


Fig.  125. — Examining  the  shoulder.     Comparing  the  relations  of  the  coracoid  processes. 

only  the  simplest  treatment:  Brace  the  arm  on  the  inside  with  a  "V" 
shaped  axillary  pad,  and  with  the  forearm  flex  at  a  right  angle;  sup- 
port the  whole  extremity  in  a  sling  of  the  Mayor  type.  Additional 
protection  may  be  afforded  by  a  shoulder  cap  (Fig.  127).  Begin  mas- 
sage early. 

2.  Oblique  Fracture  of  the  Surgical  Neck  with  Much  Overriding. — 
These  are  difficult  to  reduce;  difficult  to  maintain;  likely  to  be  mistaken 
for  dislocation. 


lk'\(   liKl      M    SHOULDEB    Willi    l>ISI.<>(  ATION. 


20I 


Reduction. — In  making  traction,  draw  downward  ami  outward  at 
OTSl  and  thru  in  the  axis  of  the  limb.  I  >0  not  slop  until  the  arm  is  the 
correct  length  by  measurement;  until  the  subcoracoid  projection  has 
disappeared;  the  acromion,  greater  tuberosity  and  the  external  i  ondyle 

are  in  the  same  straight  line.  Extension  must  be  maintained  while 
the  dressing  is  applied  or  the  displacement  will  certainly  recur.  The 
Hennequin  apparatus  described  will  he  useful  here 
and  the  plaster  splints  as  well.  Sometimes  wiring  is 
kecessary. 

3.  Fracture  of  the  Surgical  Neck  with  Dislocation. 
— This  is  a  very  serious  injury;  difficult  of  diagnosis; 
of  had  prognosis.  Carrying  out  the  systematic  ex- 
amination described,  you  find  the  head  displaced,  hut 
the  arm  is  not  fixed  in  ahduction  as  in  the  ordinary 
Dislocation;  it  drops  to  the  side.  Again,  the  head 
does  not  rotate  with  the  arm;  there  may  be  crepita- 
tion; from  these  and  other  confirmatory  points  the 
diagnosis  is  made. 

Reduction. — Anesthesia  is  necessary.  Make  a  slow, 
gentle,  hut  persistent  traction  on  the  arm;  this  com- 
bined with  manipulation  of  the  head  of  tbe  humerus 
in  the  axillary  space  may  succeed  in  restoring  the 
head  to  the  glenoid  fossa,  for  more  than  likely  the 
head  is  still  attached  to  the  shaft  by  periosteum  and 
muscular  fibers.  As  the  assistant  makes  the  traction 
apply  your  thumbs  to  the  head  in  axilla  and,  with 
the  lingers  braced  by  the  shoulder,  try  to  force  the 
head  into  place. 

Once  the  dislocated  head  is  reduced,  reduce  and  treat  the  fracture 
by  the  ordinary  means.  Massage  must  he  begun  especially  early.  If 
these  efforts  fail,  choice  lies  between  operation  and  expectant  treatment. 

Royster,  of  Raleigh,  X.  C.  (Journal  A.  M.  A.,  Aug.  10,  igoj),  re- 
views his  own  experience  and  the  literature  dealing  with  this  condition, 
and  concludes  very  Logically  that  operative  treatment  in  the  great  major- 
ity ol  cases  is  alone  effective. 

The   preferable   incision    begins   at   the   acromion    process,   extends 


r 


PlG.  i.!''.  -Frac- 
ture of  surgical 
neck  of  humerus. 
{Moullin.) 


FRACTURES. 


vertically  downward  as  far  as  necessary,  and  aims  to  reach  the  bone  by 
passing  between  the  pectoralis  major  and  the  deltoid.  The  head,  thus 
exposed,  is  to  be  reduced  by  manipulation,  although  occasionally  a 
special  hook  or  bone  forceps  may  be  necessary.  Wiring  will  seldom 
be  required  except  in  the  cases  operated  late.  The  dressing  should  be 
applied  so  as  to  maintain  the  arm  in  abduction.  Royster  believes 
in  immediate  operation,  regarding  such  cases  as  emergencies,  even  as 

strangulated  hernia  or  appendicitis. 
"Even  in  cases  of  doubt,  it  is 
preferable  to  expose  the  parts  to 
view  rather  than  to  wait  in  the 
hope  that  nature  and  time  will 
clear  it  up." 

Fracture  of  the  greater  tuberosity 
may  occur  as  the  result  of  either 
direct  or  indirect  violence,  such  as 
a  fall  upon  the  hand  with  arm  ex- 
tended. The  displacement  of  the 
tuberosity  may  be  upward,  out- 
ward, and  backward.  Early  disa- 
bility and  swelling  are  prominent 
symptoms;  crepitus  may  be  absent. 
Pain  is  produced  by  local  pres- 
sure. Taylor,  of  New  York,  as- 
serts (Annals  of  Surgery,  Jan., 
1908)  that  in  uncomplicated  cases 
with  moderate  displacement  re- 
covery may  be  practically  perfect  without  the  use  of  splints,  massage, 
or  special  movements  (Fig.  128). 

Fractures  of  the  Lower  End  of  the  Humerus. — Injuries  about  the 
elbow  are  always  to  be  regarded  seriously.  They  occur  much  more  fre- 
quently in  children  and  are  usually  due  to  falls  upon  the  flexed  elbow. 
Scudder  insists  that  even  in  the  apparently  trivial  cases  the  examina- 
tion should  be  made  under  anesthesia,  for  only  by  that  means,  as  a 
rule,  can  the  injury  be  exactly  diagnosed. 

The  diagnosis  itself  is  chiefly  a  matter  of  applied  anatomy.     The 


Fig.  127. — Fracture  of  surgical  neck. 
Axillary  pad ;  shoulder  cap ;  forearm 
supported  in  sling.      {Scudder.) 


PRACT1  I'l      \l     LOWER    END    OF    ill  Ml  Rl    -. 


203 


landmarks  ami   tin-  normal   relations   must   be  clearly  in   mind.      Ob 

serve  on  the  sound  side  die  relations  <>t"  the  interna]  and  external  ion 
Byles,  die  olecranon,  the  head  of  the  radius.     It  is  uncertain  at  first 
whether  it  is  a  contusion,  or  dislocation,  or  fracture.     Even  when  sure 


Pig.    1 28.— Fractures  through  head  of  humerus.    Patient  thrown  from  buggy  alighting 
upon  shoulder.     This  variety  of  fracture  is  mure  common  than  formerly  supposed. 


that  the  1  ase  is  a  fracture,  yet  it  is  to  be  determined  whether  it  is  supra- 
condylar, or  (  ondylar,  or  some  combination  of  the  two. 

S.  udder  formulates  a  routine  mode  of  procedure  in  making  the 
Diagnosis. 

Observe  the  character  of  the  swelling— whether  general  or  Localized. 

Observe  the  carrying  angle. 


204 


FRACTURES. 


Palpate  the  external  and  internal  condyles. 
Palpate  the  olecranon  process  and  head  of  the  ulna. 
Rotate  the  head  of  the  radius. 


Fig.  129. — Examining  the  elbow;  locating  the  three  cardinal  points — the  internal 
condyle,  the  tip  of  the  olecranon  and  the  external  condyle. 

Note  the  relation  of  the  three  bony  points  in  extension  and  flexion 
(Fig.  129). 

Determine  the  possible  movements  of  the  elbow-joint.  Make 
measurements.     Make  pressure  with  the  point  of  the  finger  to  locate 


SI  PB  \  CONDI:  I  \\i    FRACTURES. 


205 


a  painful  line   which   marks  the   fracture.     If  the  X  ray  is  used  it 
should  show  both  the  lateral  and  antero  posterior  view. 

Certain  forms  of  injury  arc  found   most   frequently:     (1)  Supra 
condylar  fracture,  (2)  fracture  of  one  of  the  condyles,  (3)     multiple 
fracture  involving  the  jo:nt. 

(1)  Supra-condylar  Fracture. — The  joint  is  not  usually  Involved, 
the  plane  of  fracture  extending  commonly  from  above  downward  and 
forward.  The  displacement  of  the  upper  fragment,  therefore,  is 
downward  and  forward,  and  if  union  takes  place  in  this  position  the 
flexion  of  the  elbow  is  much  abbreviated  (Fig.  130). 

Reduction.—  ( >ften   the  ordinary   means,   that   is   by   traction   and 


PlG.  130. — Supra -condylar  fracture  of  humerus.     Note  obliquity.      (Moullhi.) 


countertraction  with  the  forearm  Hexed,  will  not  succeed.  Try  slow 
and  progressive  traction  upon  the  extended  forearm,  aided  by  manipula- 
tion of  the  fragments  at  the  site  of  fracture  (Fig.  131). 

When  reduction  is  complete,  continue  the  traction  but  gently  Ilex 
the  elbow  to  an  acute  angle;  if  no  displacement  occurs,  and  if  the 
swelling  is  not  so  great  as  to  preclude  flexion  by  reason  oi  the  inter- 
ference with  the  brachial  artery,  proceed  to  apply  the  fixation  dressing. 
The  molded,  posterior  plaster  splint,  or  trough,  is  recommended. 

Twelve  to  sixteen  pieces  of  crinoline  long  enough  to  reach  from  the 
deltoid  insertion  to  near  the  wrist,  and  wide  enough  to  cover  the  arm, 
are  quilted  together  and  two  oblique  notches  cut  corresponding  to  the 
bend  of  the  elbow.  This  piece  of  padding  is  now  impregnated  with 
liquid  plaster  and  applied  to  the  back  of  the  arm  and  forearm,  and 


2o6 


FRACTURES. 


well  molded.  The  two  notches  permit  a  ready  adjustment  at  the  bend 
of  the  elbow.  The  support  of  the  arm  is  not  relaxed  until  the  plaster 
has  hardened.  The  gutter  thus  formed  may  be  strengthened  by  a 
loosely  applied  roller  which  passes  from  the  wrist  across  to  the  arm 
near  the  axilla,  around  it  and  back  to  the  wrist  again,  and  so  on.  The 
arm  is  thus  fixed  in  acute  flexion. 

A  boy  of  twelve  years  was  brought  in  from  the  country  with  an  in- 


Fig.  131. — Supra-condyloid  fracture  of  the  humerus.  Method  of  reduction  before 
applying  retentive  splint.  Countertraction  on  upper  arm.  Traction  on  condyles 
of  humerus  with  right  hand;  backward  pressure  with  thumb  of  left  hand.  Also 
illustrative  of  method  of  beginning  acute  flexion.      (Scudder.) 

jury  received  the  day  before  by  being  thrown  from  a  horse.  A  diag- 
nosis of  fracture  about  the  elbow  had  been  made,  and  with  it  the 
effort  to  fix  the  arm  in  forced  flexion.  The  whole  member  was 
greatly  swollen,  edematous  about  the  elbow  with  blebs  in  process  of 
formation.  The  X-ray  confirmed  the  diagnosis,  showing  epiphys- 
eal separation  with  fracture  and  separation  of  the  internal  condyle 
(Fig.  132).  The  dressing  was  removed,  the  arm  fixed  in  extension; 
daily  massage  was  instituted  to  remove  the  tumefaction,  and  after  four 
days  an  effort  was  made  to  reduce  the  fragments  and  put  the  arm  in 
forced    flexion;  but  this  only  resulted  in  complete  obliteration  of  the 


PRACTUR]     «'l     llll     CONDYLES. 


207 


radial  pulse.  The  arm  was  left  in  semiflexion  and  pronation,  and 
massage  was  again  instituted  i'<>r  a  few  days;  gradual!]  the  swelling 
subsided,  and  after  the  end  of  a  week  more  another  effort  was  made 
to    reduce    under    general    anesthesia,    with    better   results.     After 


Fig.  13.?. — Supra-condylar  fracture  of  humerus,  lower  fragment  displaced 
upward  and  backward. 


a  week  of  fixation  in  the  correeted  position  the  massage  was  begun 
again  and  continued  for  some  weeks.  Eventually  the  restoration  of 
function  was  almost  complete. 

(2)  Fracture  of  the  Condyles. — If  the   internal  condyle   is  broken. 


208 


FRACTURES. 


swelling  is  marked  over  the  inner  side  of  the  elbow.  The  condyle 
can  be  grasped  between  the  fingers  and  crepitus  elicited.  The  inner 
of  the  three  bony  points  is  displaced  upward,  which  diminishes  the 
carrying  angle.     The  ulna  is  displaced  upward  in  extension  (Fig.  134). 


Fig.  133. — Fracture  of  external  condyle  of  humerus  in  a  child.     The  small  mass 
near  the  joint  line  is  the  epiphysis  of  the  radius. 


If  the  external  condyle  is  broken  the  swelling  is  most  noticeable 
externally.  Although  the  external  condyle  is  dislocated,  its  relations 
to  the  head  of  the  radius  are  not  changed.     The  fragments  in  either 


I\  I  I  RCONm  LAB    FRACT1   R]  5. 


209 


case  are  Likely  to  be  easily  reduced  by  pressure,  bul  the  displacement 
immediately  recurs  when  the  pressure  is  removed  (I'ig.  133). 

Reduction.  ( Irasp  the  condyle  between  the  finger  and  thumb  of 
one  hand  and  make  pressure  in  the  bend  of  the  elbow  with  the  other, 
and  while  the  assistant  slowly  brings  the  forearm  Into  the  position  of 
acute  flexion,  manipulate  the  condyle  into  place. 


PlG.  134. — Frac- 

ture   of    internal    con- 
dyle.     (Moullm.) 


Fig.  13s. — Intercondylar  fracture 
of  humerus.     (Monti  in.) 


Treatment. — Scudder  strongly  recommends  fixation  in  this  position 
of  acute  flexion,  maintaining  it  by  passing  an  adhesive  strip  three 
inches  wide  about  the  wrist  and  upper  arm,  supporting  the  whole  with 
a  sling.  He  emphasizes  the  necessity  of  watching  the  circulation  in 
the  forearm  and  regulating  the  degree  of  flexion  by  the  amount  of 
swelling. 

(3)  The  intercondylar  and  multiple  fractures  involving  the  joint, 
as  they  do,  require  a  very  guarded  prognosis  (Fig.  135).  By  referring 
m 


2IO  FRACTURES. 

to  the  landmarks,  the  displacements  are  to  be  figured  out  and  the 
fragments  are  to  be  manipulated  until  all  the  movements  of  the  joint 
are  restored. 

The  forearm  is  then  to  be  acutely  flexed  and  fixed  either  by  the 
adhesive  strips,  or  plaster  splints  as  before  described.  If  the  dis- 
placements cannot  be  held  by  this  means  the  fracture  must  be  treated 
by  extension  for  a  few  days  and  then  put  up  in  acute  flexion.  Massage 
and  passive  motion  must  be  very  early  begun  in  these  cases  and  per- 
sisted in  for  a  long  time. 

FRACTURES  OF  THE  FOREARM. 

Fracture  of  the  shaft  of  the  ulna  and  radius  occurs  more  commonly 
in  the  middle  third,  both  bones  being  broken  or  only  one.  If  both 
are  broken,  the  radius  is  likely  to  be  broken  at  a  higher  level  than  the 
ulna.  There  is  usually  not  much  deformity  if  one  bone  is  fractured; 
considerable  if  both  are  (Fig.  136). 

The  diagnosis  is  to  be  made  from  the  pain,  deformity,  mobility,  and 
crepitation;  supination  is  particularly  painful  if  the  radius  is  broken; 
lateral  compression  of  the  bones,  even  at  some  distance  from  the  seat 
of  fracture,  may  elicit  much  pain  at  the  site  of  fracture. 

Reduction. — Flex  the  forearm  at  a  right  angle;  direct  the  assistant  to 
make  countertraction  from  the  arm;  grasp  the  hand,  place  the  arm 
in  complete  supination  and  make  traction  in  the  axis  of  the  forearm, 
molding  the  fragments  into  place;  the  fingers,  following  the  interosseous 
space  down  the  front  of  the  arm  help  to  force  the  fragments  apart. 
The  preservation  of  the  interosseous  space  is  the  essential  thing.  The 
extension  and  supination  must  be  maintained  until  the  dressing  is 
applied.  Whatever  its  form,  the  fixation  must  have  one  negative 
quality — it  must  not  compress  the  forearm  laterally  or  else  the  bones 
may  be  pressed  toward  each  other  and  fusion  occur. 

Anterior  and  posterior  splints  may  be  used,  both  wider  than  the 
forearm.  The  anterior  must  extend  from  the  bend  of  the  elbow  to 
the  base  of  the  fingers;  the  posterior  must  extend  from  the  elbow  to 
the  wrist.  They  may  be  shaped  out  of  boards  and  well  padded.  The 
palm  must  be  well  padded.     The  splints  are  first  secured  with  adhesive 


i  k\n  \  \<\    in    mi:   ioki    \i-\i. 


21  I 


■trips  and  then  with  a  roller  bandage.     The  elbow  is  t<>  be  immobilized 
l>y  suspension   of   forearm   and   hand   in   a   sling   (Fig.    137).     ( 'arc- 
must  be  taken  not  to  compress  the  bra<  hial  artery  or  the  bony  points. 
[nstead  of  the  anterior  and  posterior  splints  a  plaster  cast  mav  be 


Pig.  136. — Fracture  of  tlu- shaft  of  ulna  with  separation  of  the  epiphysis;  fracture 
of  the  shaft  of  the  ra<lius,  too  high  for  a  Colics'  fracture. 

used,  extending  from  the  axilla  to  the  palm  of  the  hand,  immobilizing 
the  wrist  and  elbow;  care  must  he  taken  not  to  compress  the  forearm 
[Figs.  138,  139). 

Lejars  recommends  tlu-  plaster  splint  formed  in  this  manner:  twelve 


212  FRACTURES. 

to  fifteen  sheets  of  crinoline  cut  in  the  form  of  an  irregular  quad- 
rilateral, long  enough  to  reach  from  the  bend  of  the  elbow  to  the 
palmar  crease,  wide  enough  above  to  encircle  the  arm;  below,  wide 
enough  to  more  than  encircle  the  wrist,  are  loosely  quilted  together. 
In  the  middle  of  the  lower  end,  one  inch  from  its  border,  cut  an  oval 
opening  large  enough  to  pass  the  thumb.  This  dressing,  soaked  with 
plaster  and  molded  to  the  forearm,  furnishes  a  firm  fixation. 

Colles'  Fracture. — This  break  at  the  lower  end  of  the  radius  is 
quite  common  and  is  more  often  due  to  a  fall  upon  the  outstretched  pal  m. 
The  lower  fragment  is  pushed  toward  the  dorsal  surface  and  overrides, 


■" 


Fig.  137. — Anterior  and  posterior  splint  for  forearm.      {Heath.) 

producing  the  characteristic  hump — the  silver  fork  deformity.  But 
it  is  by  no  means  seldom  that  fracture  occurs  without  deformity 
(Fig.  140).  In  addition  to  the  injury  to  the  bone,  the  inter-articular 
fibrocartilage  may  be  torn  loose  from  both  its  attachments,  the  radio- 
ulnar ligaments  are  strained  or  ruptured,  and  the  head  of  the  ulna 
carried  forward.  Sometimes  the  tendon  sheaths  are  lacerated  and 
blood  extravasated  into  the  synovial  sac  (Fig.  141). 

Diagnosis. — Determine  the  position  of  the  styloid  processes  of  the 
radius  and  ulna.  If  there  is  a  fracture  the  styloid  of  the  radius  is 
pushed  up  to  a  level  with  that  of  the  ulna,  the  wrist  is  broadened.  The 
transverse  lines  on  the  flexor  surface  of  the  wrist  are  deepened  and  the 
axis  of  the  limb  bent  toward  the  radial  side.  The  pain  is  pronounced, 
mobility  and  crepitus  are  absent.  Pain  is  elicited  by  point  pressure 
across  the  radius. 


FRACTURK    OF    THE    FORE-ARM.  21} 


Pio.  138. — Method  of  supporting  arm  while  applying  plaster  bandage. 


Fig.    [39.     Fracture   of   forearm.     Plasti  iplinl 

applied.     Elbow  at  right  angle. 


214 


FRACTURES. 


The  X-ray  is  very  useful  in  diagnosis  of  these  fractures. 

Reduction  is  often  difficult,  but  it  is  the  chief  thing  and  must  be 
complete,  otherwise  the  result  will  be  a  disappointment.  Anesthesia 
is  usually  necessary.     Clasp  the  patient's  hand  in  your  own,  palm  to 


Fig.  140. 


-Typical  Colles'  fracture:  impacted  fracture  of  lower  end  of  radius  and 
fracture  of  styloid  process  of  ulna. 


palm,  and  with  the  other  hand  grasp  the  wrist  at  the  site  of  fracture. 
While  the  assistant  makes  countertraction  you  make  forcible  traction 
on  the  hand,  at  the  same  time  inclining  it  to  the  ulnar  side  and  making 
pressure  upon  the  fragments.     This  combined  traction,  pressure  and 


RKIH'CTION    ol''    col. I. IS      I'RAC]  URE 


2'5 


ulnar  flexion  may  require  Force,  bul  it  wil]  quickly  reduce  the  fracture 
ffig.  142). 

There  is  very  little  tendency  to  recurrence  of  the  deformity  ii  it  is 
properly  reduced,  and  the  fixation  is  a  secondary  matter.  If  there 
was  no  deformity,  or  a  very  slight  one  easily  reduced,  it  may  be  treated 


Fig.  141. — Colics'  fracture.      Silver  fork  deformity.      (Monllin.) 

altogether  by  massage.  Otherwise  a  week's  fixation  in  one  of  the 
dressings  just  described  is  advisable,  to  be  followed  by  active 
massage. 


PlG.  142. — Reduction  of  Colles'  fracture.  Note  grasp  upon  firearm  and  the 
lower  fragment  of  the  radius,  traction  and  countertraction  being  made;  breaking 
up  the  impaction.     (ScudderJ 


Andrews,  of  Mankato,  Minn.,  emphasizes  the  necessity,  in  a  reduc- 
tion of  this  fracture,  of  a  general  anesthesia  and  a  knowledge  of  the 
anatomy  of  the  parts,  which  latter  will  be  of  more  value  to  the  tyro  than 
any  confusing  description  of  the  manner  of  taking  hold  of  the  parts, 


2l6  FRACTURES. 

He  remarks  further  that  the  head  of  the  ulna  must  be  brought  back  to 
rest  in  the  sigmoid  of  the  radius. 

Thinking  the  fracture  set  when  merely  the  lower  fragment  of  the 
radius  is  in  position  is  a  mistake  that  has  brought  sorrow  to  many 
a  surgeon  after  union  has  taken  place. 

The  most  frequent  permanent  deformity  is  the  slumping  forward  of 
the  ulna  and  the  widening  of  the  wrist.  Andrews  does  not  believe 
that  early  passive  motion  does  a  great  deal  of  good  and  may  do  harm 
by  keeping  the  joint  irritated  by  increasing  the  amount  of  callus  and 
by  causing  useless  suffering.  Early  massage,  if  gentle,  is  not  only 
permissible,  but  to  be  recommended  (Amer.  Jour.  Surg.,  July,  1909). 

Fracture  of  the  Olecranon. — This  break  is  usually  due  to  direct 
violence,  sometimes  to  muscular  action.  The  amount  of  separation 
of  the  fragments  depends  upon  the  amount  of  the  tear  in  the  fibrous 
attachments  of  the  triceps,  and  is,  of  course,  most  marked  in  flexion, 
and  is  increased  by  swelling  of  the  joint.  A  complete  fracture  opens 
into  the  joint. 

Much  difference  of  opinion  exists  as  to  the  treatment.  It  is  obvious 
that  no  one  method  is  equally  applicable  to  all  cases.  There  can  be  no 
doubt  that  the  method  of  choice,  where  it  is  possible,  is  suturing. 

If  this  is  not  advisable,  or  not  permitted,  the  next  best  procedure 
is  the  treatment  by  massage  begun  immediately — and  this  whether 
there  is  much  or  little  separation.     No  immobilization,  only  massage. 

If  asepsis  can  be  assured  or  if  the  fracture  is  compound,  suture  is 
indicated.  The  operation  is  not  difficult.  The  bone  is  exposed  by  a 
transverse  incision,  or  if  there  is  a  wound  it  may  be  enlarged.  Cleanse 
the  wound  of  all  exudates  and  trim  away  the  ragged  tissues;  next  expose 
the  fracture,  separate  the  fragments  and  expose  and  cleanse  the  joint. 

There  are  several  methods  of  suture.  If  the  fracture  is  transverse, 
the  periosteum  on  each  side  is  laid  back  and  two  holes  drilled  in  each 
fragment  for  the  passage  of  two  silver  wires.  When  a  wire  is  passed 
its  ends  are  twisted  and  the  coaptation  perfected.  The  drill  holes 
should  not  involve  the  cartilage.  The  wires  are  cut  short  and  ham- 
mered down  smooth,  and  the  periosteum  and  fibrous  sheath  sutured, 
and  the  skin  wound  repaired  without  suture.  The  arm  is  immobilized 
in  flexion  for  eight  or  ten  days  and  then  massage  is  begun. 


Sl'Tl'KK    OF    i\<  \(  Tlkll)    ul. I  ik  \\m\. 


217 


If  the  fragments  are  split,  they  may  be  eat  b  perforated  from  without 

inward  and  a  suture  passed  and  tied  on  tin-  outer  side-.      By  this  mean-. 

tin1  Fragments  art'  all  drawn  into  coaptation.  If  the  upper  fragment 
is  small  the  upper  transverse  perforation  may  involve  only  tin-  tendon. 
A  carpenter  fell  from  his  ladder,  striking  the  point  of  his  elbow  upon 
the  -harp  edge  of  a  timber.  The  joint  was  laid  wide  open,  the  olec- 
ranon broken  across  transversely  and  split  as  well.      At  the  Deaconess 


PlG.   143. — Suture  of  the  olecranon.     The  suture  in  the  form  of  a  transverse  loop 
perforates  the  lower  and  two  upper  fragments.      (Schwartz.) 


Hospital  the  joint  was  cleansed  thoroughly  with  normal  salt  solution, 
the  mangled  tissue  trimmed  away.  The  fragments  were  exposed  by 
free  use'  of  the  rugine.  Two  transverse  holes  were  drilled,  the  upper 
one  including  both  fragments  (Fig,  [43).  Chromicixed  catgut  was 
used  to  draw  the  fragments  together.  The  single  suture  was  quite 
Sufficient  to  secure  coaptation.  A  small  drainage-tube  was  left  in  the 
joint  cavity.  The  periosteum  was  repaired  (Fig.  144),  and  the  soft 
parts  closed  with  additional  drainage.  After  the  third  day,  the  tube  in 
the  joint  cavity  was  removed  permanently.      There  w  as  a  little  suppura- 


2l8 


FRACTURES. 


tion  in  the  soft  parts  and  the  superficial  drainage  was  retained  for  a 
week.  At  the  end  of  ten  days  the  soft  parts  being  healed,  the  position 
of  the  elbow  was  changed  from  extension  to  flexion  and  daily  passive 
motion  and  massage  was  begun.  The  result  was  perfect  use  of  the  joint. 
J.  B.  Murphy  has  devised  and  recommends  a  method  of  subcutane- 
ous  suture    (Jour.   Am.   Med.    Assn.,    Jan.    27,    1906).      Begin  by 


Fig.  144. — Suture  of  the  olecranon.     Repairing  the  periosteum  by  a  continuous 
catgut  suture.      (Schwartz.) 


making  a  small  incision  over  the  external  border  of  the  olecranon 
below  the  line  of  fracture.  Through  this  small  opening  (1  1/3  inches) 
drill  the  olecranon  transversely,  and  over  the  point  of  emergence  of  the 
drill  on  the  inner  border  of  the  olecranon  incise  the  skin  again.  An 
aluminum-bronze  wire  is  passed  through  the  drill-hole  from  without 
inward  and  the  inner  end  is  pushed  up  under  the  skin  along  the  internal 


I'RAi    I  I   I' I     'il      \RPUS. 


2  I  <) 


border  of  the  olecranon  to  the 
level  of  the  apex  of  the  bone. 
At  this  level  another  incision  is 
made,  the  end  of  the  wire  re- 
covered and  pushed  through 
the  tendon  of  the  triceps  from 
within  outward.  A  fourth  small 
incision  is  made  over  the  end  of 
the  wire  to  the  outside,  and  the 
end  of  the  wire  again  directed 

under    the    skin   to  the  Starting        Pig.    i4S.— Showing  " sway-backed''  appear 

°    ance  after  fracture  of  the  first  phalanx  of  inn  Idle 

point  and  there  tied  tightly,  in   fin«er-    Worsee.) 

that  manner  approximating  the  fragments.     Close  the  skin  wounds. 

Fractures  of  Carpus  and 
I  laud. — Fractures  of  the  bones 
of  the  carpus  are  not  infrequent, 
and  may  occur  with  fractures 
at  the  lower  end  of  the  radius. 
The  scaphoid  is  probably  the 
most  frequently  involved,  either 
alone  or  with  one  of  the  other 
bones.  The  injury  results 
most  frequently  from  a  fall 
upon  the  hand  when  it  is  ex- 
tended and  abducted. 
Fracture  will  be  suspected  from  the  pain  and  loss  of  function,  and 
on  examination  the  styloid 
process  of  the  radius  is  found 
too  i  lose  to  the  base  of  the  first 
metacarpal,  and  the  "tabatiere 
anatomique" — the  depression 
at  the  base  of  the  thumb  be- 
tween the  long  and  short  ex 
tensors  of  the  thumb — is  occu- 
pied   by   a    hard    body.      Point 

e     ,  Pig    i  i:      Mode  of  adjusting  splint  for  simple 

pressure    in     case     ot     fracture  fracture  of  the  finger.     (Mm 


PlG,    146.— Splinl   with    attachment    for  correc- 
tion of  lateral  cleformity.     {Marscc.) 


220 


FRACTURES. 


Fig.  148. — Splint  wrapped  with  gauze  ad- 
justed for  fracture  of  first  phalanx,  index  finger. 
(Marsee.) 


elicits  much  pain.     Often  the  thenar  eminence  is  ecchymosed.     The 

exact  character  of  the  lesion 
can  only  be  determined  by  the 
X-ray.  Reduction  may  be  ac- 
complished by  putting  the  hand 
on  the  ulnar  flexion  and  mak- 
ing pressure  on  the  fragments 
through  the  palm.  Excision 
may  be  necessary. 

Fracture  of  the  metacarpals 
is  to  be  reduced  by  traction  on 
the  corresponding  fingers,  com- 
bined with  pressure  on  the  fragments.  Immobilization  on  a  simple 
splint  for  eight  or  ten  days,  followed  by  massage,  will  give  good  results. 

Fracture  of  the  fingers  is 
sometimes  compound,  requir- 
ing a  careful  antisepsis.  There 
is  usually  a  tendency  to  dis- 
placement, so  that  after  reduc- 
tion splinting  is  necessary.  A 
well-padded  palmar  splint  is 
often  all  that  is  necessary,  re- 
taining it  by  bandages  or  ad- 
hesive strips. 

In  many  cases,  however,  the  matter  is  not  so  simple  and  it  cannot 

be  denied  that  the  splints  ordi- 
narily used  are  often  very  un- 
satisfactory, for  they  are  not 
seldom  so  fashioned  as  to  be 
inadequate  to  maintain  exten- 
sion, to  immobilize  perfectly, 
or  to  correct  deformity. 

The  first  or  proximal  phalanx 
most  frequently  suffers  and  the 
fragments  are  likely  to  bulge 
a   "sway-backed"  appearance 


Fig. 


149. — Finger 
aspect. 


splint      applied. 
{Marsee.) 


Dorsal 


Fig. 


150. — Splint     applied. 
{Marsee.) 


Palmar    aspect. 


toward   the   palm,   giving   the   finger 


IK  \<    I  I    Kl      (MUM       I  [NGKRS. 


221 


PlG.  i  S  i  ■ — Lateral  angular  deformity  of 
middle  finger.  Unsightly.stump  of  index. 
(Alarsee.) 


(Fig.  i  15).  As  Marsce  has  pointed  out,  this  deformity  will  not  yield 
to  the  ordinary  splinl  nor  indeed  to  any  splint  which  is  straight  or 
hut  slightly  curved. 

The  appliance  recommended  for 
this  condition  and  which  may  lie 
useful  in  any  fracture  of  the  digits 
consists  of  a  strip  of  tin,  zinc,  cop- 
per, or  galvanized  iron,  fourteen 
inches  long  and  two  and  one-half 
inches  wide.  This  is  to  be  folded 
upon  itself  lengthwise  and  ham- 
mered flat  so  as  to  make  a  three- 
lily  strip  three-fourths  of  an  inch 
in  width.  Of  whatever  material 
made,  it  should  he  just  flexible 
enough  to  he  bent  readily  by  the 
unaided  fingers.  Upon  one  end  of 
the  strip,  a  piece  of  thin  leather  or 
canvas  four  or  five  inches  long  and 

three  inches  wide  is  to  be  riveted  (Fig.  146)  in  order  to  give  the  strip 

stability  when  bandaged  to  the 
forearm.  The  strip  is  then 
shaped  to  suit  the  curved  outline, 
in  which  position  the  fingers 
should  be  immobilized  (Fig.  147, 
14S).  The  splint  is  to  be  ad- 
justed snugly  to  the  forearm,  so 
that  its  end  projects  slightly  be- 
yond the  tip  of  the  linger,  and 
fastened  by  strips  of  adhesive 
plaster,  by  a  roller  bandage,  or  by 
a  light  plaster-of-Paris  casing. 
The  finger,  carefully  wrapped  in 
several  thicknesses  of  gauze, 
is  then  adjusted  with  painstaking  tan-  to  the  splint  in  such 
a   manner  that   the  deformity,   if  any,   is   thoroughly  overcome,   and 


Pu 


152. — Crushed      hand.      Lateral      angular 
deformity  of  little  finger.     (Marsee.) 


FRACTURES. 


longitudinal  and  circular  strips  of  adhesive  plaster  are  applied  (Figs. 
149,  150). 

In  this  manner,  almost  complete  control  of  the  finger  is  assured. 

When,  however,  the  lateral 
angular  deformity  is  pro- 
nounced (Figs.  151,  152),  some 
modification  of  the  apparatus 
may  be  necessary. 

Two  or  three  strips  of  zinc 
or  copper  are  cut  out  two  and 
one-half  inches  long  and  half 
an  inch  in  width.  These  are 
bent  by  one  end  around  the 
splint,  fitting  it  snugly  but  yet 
capable  of  being  slipped  back- 
The  free  end  is  left  wide  and  is 
This  lateral  support  may 


Pig.  i53- 


—Splint  applied  to  prevent  lateral 
angularity.      (Marsee.) 


ward  and  forward  along  the  splint 
bent  up  to  give  the  finger  lateral  support 
be  slipped  along  to  the  desired 
point  and  effectually  corrects  the 
deformity  (Fig.  r53). 

Should  two  or  more  fingers 
be  broken,  several  strips  may 
be  used  side  by  side,  but  fast- 
ened to  the  same  flange  of 
leather  or  canvas.  For  two 
fingers,  a  splint  of  double  width 
may  be  fashioned. 

Should  the  thumb  be  broken, 
the  splint  may  be  heated  and 
bent  laterally  in  proper  shape, 
or  an  arm  may  be  riveted  to  the 
ordinary  strip. 

If  the  fracture,  or  dislocation 
is  compound,  especially  if  attended  with  much  displacement  and 
difficulty  in  maintaining  reduction,  the  fragment  should  be  exposed 
and  wired,  for  which  one  needs  only  a  small  drill  or  awl,  a  fine  steel 


Fig.  154. — Suturing  bones  of  finger. 
Drilling.      (Marsee.) 


STAVE    OF    I  in      1 1 1 1  Mi:. 


223 


crochet  hook  and  chromicized  gut  (Figs.  154,  155).  Such  is  the 
method  taught  by  Marsee. 

The  after-treatment  is  of  importance.     The  splint  will  be  required 
probably  for  two  weeks  or  longer,  but  in  order  to  prevent  stiffness, 
passive  motion  should  be  begun  at  the  end  of  the  first  week  and  re 
peated  every  other  day  at  first.     The  fragments  must  be  held  in  |  lacs 
during  the  first  seances.     Un- 
der this  treatment,  the  stiffness 
and     soreness     will     disappear 

together. 

If  it  is  the  base  of  the  meta- 
carpal of  the  thumb  which  is 
broken,  the  reduction  will  be 
difficult  to  maintain,  and  it  will 
probably  be  necessary  to  splint 
for  two  or  three  weeks.  This 
is  Bennett's  fracture  or  "Stave 
of  the  thumb."  RlISS,  of  San 
Francisco,  who  has  given  the 
subject  special  consideration, 
states  (J.  A.  M.  Assn.,  June 
16,  1906)  that  with  an  increase 

of  Bennett's  fracture  in  their  dispensary  book,  there  has  been  a 
marked  decrease  in  their  diagnosis  of  sprains  of  the  thumb  and  sub- 
luxations of  the  metacarpo-trapezial  joint.  He  believes  it  to  be  the 
most  common  and  most  important  of  the  metacarpal  fractures.  He 
uses  three  well-padded  pencil  splints,  many  cases  requiring  a  marked 
abduction  of  the  thumb. 


Fir.  155. — Suturing  bones  of  finger.      Drawing 
suture  through  with  crcchet  hook.  (Marsee/) 


FRACTURES  OF  THE   LOWER   EXTREMITY. 

The  first  aid  in  these  cases  is  of  special  importance,  as  has  already 
been  indicated.  Even  more  than  elsewhere  the  principle  applies  that 
there  must  be  absolutely  as  little  motion  as  possible  in  order  that  the 
patient  may  be  spared  pain  and  augmented  shock;  that  the  deformity 
may  not  be  aggravated  and  the  periosteum  and  other  soft   parts  lac 


224  FRACTURES. 

erated;  and  that  a  simple  fracture  may  not  be  converted  into  a  com- 
pound one  with  all  the  additional  dangers  of  infection.  The  method 
of  lifting  a  patient  so  injured  has  already  been  described. 

Fracture  oe  the  Femur. 

The  treatment  and  prognosis  of  fractures  of  the  thigh  vary  with 
their  location,  and,  with  reference  to  these  points,  they  are  divided  into 
three  classes:  (i)  those  involving  the  upper  end,  (2)  those  involving 
the  shaft,  (3)  those  involving  the  lower  end. 

(1)  Fractures  of  the  upper  end  of  the  femur  have  been  the  subject  of 
much  discussion,  and  various  forms  of  treatment  have  been  recom- 
mended for  imagined  clinical  and  anatomical  varieties.  At  the  pres- 
ent time,  nearly  all  surgeons  are  of  the  opinion  that  these  lesions  may 
be  grouped  under  two  heads,  impacted  and  non-impacted.  Even 
this  division  is  not  important  for  diagnosis,  but  only  for  prognosis, 
since  impaction,  provided  it  is  not  broken  up,  offers  the  conditions  most 
favorable  for  bony  union  (Fig.  156). 

Although  the  differential  diagnosis  is  usually  difficult,  sometimes 
impossible,  yet  the  presence  of  a  fracture  of  some  kind  is  usually 
determined  after  a  little  study.  A  severe  contusion  may  indeed  be 
mistaken  for  fracture,  but  this  is  not  a  serious  error.  On  the  other 
hand,  it  is  a  very  serious  error  to  mistake  and  treat  a  fracture  about 
the  hip  as  a  contusion.  In  case  of  unresolvable  doubt,  treat  the 
injury  as  a  fracture.     The  diagnosis  is  made  from  several  factors: 

(a)  Pain  is  a  symptom  upon  which  one  cannot  greatly  rely.  It  is 
more  constant  in  impacted  than  non-impacted  fracture  because  of 
the  accompanying  bruises  of  the  soft  parts.  The  pain  is  aggravated 
by  pressure  over  the  hip.  Tenderness  and  especially  a  fullness  in 
Scarpa's  triangle  is  frequently  observed. 

(b)  Loss  of  function  may  alst)  be  due  to  contusion;  moreover,  the 
patient  may  be  able  to  walk  with  an  impacted  fracture,  so  that  this 
symptom  is  no  certain  criterion.  However,  the  patient  is  usually 
unable  even  to  draw  his  heel  upward. 

(c)  Eversion  of  the  foot  is  nearly  always  present  in  some  degree, 
but  is  more  frequently  indicative  of  non-impacted  than  impacted 
fracture,  and  is  due  to  the  weight  of  the  limb. 


I  is  \<   I  i  ki     i  >i     llir    NECK    01     mi     FEMUR. 


225 


(d)  Shortening  is  more  frequently  the  accompaniment  of  impacted 
fracture.  It  is  definitely  determined  by  comparing  with  the  sound 
side,  measuring  from  the  anterior  superior  spine  (be  sure  the  pelvis 


Pic.  156. — Impacted  fracture  of  the  anatomical  neck  of  the  femur. 


is  not  tilted)  to  the  internal  condyle  and  internal  malleolus;  also  by 

determining  the  relation  of  the  trochanter  to  Nelaton's  line  (Fig.  157). 

(c)  Crepitation   is   proof  incontestable  but  rarely   available.     One 

should  make  no  effort  to  elicit  this  symptom,  fearing  to  break  up  im- 

15 


226 


FRACTURES. 


paction,  which  is  an  accident  much  to  be  deplored,  according  to  the 
usually  accepted  view. 

Senn  (Practical  Surgery)  says  upon  this  point  that  it  is  better  to  be 
satisfied  with  the  probable  evidence  of  fracture.  If  the  surgeon  in 
his  anxiety  to  obtain  a  perfect  diagnosis  moves  the  limb  freely  in  all 

directions,  he  overcomes  impaction,  rup- 

rturing  the  cervical  ligaments,  demon-;; 
strating  beyond  all  doubt  the  existence 
of  the  fracture  and  at  the  same  time 
effectually  destroying  all  hope  of  reunion. 
As  Senn  suggests,  a  useless  limb  is  cer- 
tainly a  high  price  to  pay  for  a  perfect 
diagnosis. 

The  treatment  resolves  itself  into  two 
lines  of  procedure,  depending  upon 
whether  or  not  the  fracture  is  impacted. 
In  either  case  the  treatment  should  be 
modified  by  the  age  and  constitution  of 
the  patient.  Confinement  on  the  back 
may  be  fatal  in  the  aged,  and  it  is  impera- 
tive in  such  cases  to  give  the  patient  more 
freedom.  This  imperfect  immobilization 
may  eventually  result  in  an  imperfect 
union,  but  one  must  be  consoled  by 
the  reflection  that  a  fatal  attack  of 
I57.-Measurement     of   hypostatic    pneumonia    may   have  been 

lower    extremity.     Patient    lying  t    J 

on  the  back  looked  at  from  above,     preveilieu. 

^oteZtedaP&deSr:rd  Hmbs       In  the  case  of  undisturbed  impaction, 

the  treatment  is  of  the  simplest  form. 
The  patient  is  placed  on  a  smooth  mattress,  the  limb  supported 
by  sand  bags  or  perhaps  light  extension  applied,  and  systematic 
massage  early  instituted.  In  case  there  is  much  shortening  with 
non-impaction  and  the  patient's  condition  will  permit,  then  the  case 
must  be  treated  on  the  same  principles  as  fracture  of  the  shaft. 
Senn  advises  prolonged  immobilization  in  a  plaster  cast,  which 
extends  from  the  foot  to  the  umbilicus,  and  is  fenestrated  for  the 


ABDU<  HON    in    FRACTURE    or   nil.    FEMUR.  227 

purpose  of  applying  Lateral  pressure,  which  he  regards  as  essential 
to  good  union. 

J.  B.  Walker,  of  New  York,  is  not  in  accord  with  the  dictum  that 
impacted  fractures  of  the  Deck  of  the  femur  should  not  be  disturbed, 

and  Whitman  arees  with  him  (Annals  of  Surgery,  January,  1908). 
Unless  the  condition  of  the  patient  forbids,  he  proceeds  gently  to  break 
up  the  impaction  under  anesthesia.  The  limb  is  reduced  by  extension 
and  gradual  abduction  to  an  angle  of  forty-five  degrees,  in  the  mean- 
time supporting  the  upper  end  of  the  femur  and  rotating  the  leg  inward. 

In  this  position,  the  limb  is  well  covered  with  cotton  batting,  all  the 
bony  boints  especially  well  protected  and  a  flannel  bandage  smoothly 
applied.  A  plaster  spica  is  now  applied  extending  from  the  lower 
ribs  to,  and  including,  the  foot.  The  plaster  fits  the  pelvis  snugly 
and  is  molded  close  to  the  trochanter  and  posterior  aspect  of  the  joint. 
It  is  also  molded  to  the  patella  and  condyles,  and  to  the  foot  to  prevent 
rotation.  This  dressing  permits  the  patient  to  rise  up  in  bed  without 
much  discomfort.  Walker  concludes  from  his  experience  that 
fracture  of  the  neck  of  the  femur  occurs  under  fifty  years  more  fre- 
quently than  formerly  believed;  any  injury  of  the  hip  followed  by  dis- 
ability should  suggest  fracture  and  calls  for  expert  examination,  aided 
by  the  X-ray  wherever  possible;  that  reduction  of  deformity  and 
immobilization  by  plaster  bandage  in  all  suitable  cases  should  be 
practised;  that  early  gymnastic  exercise  is  advisable;  and  that  the 
weight  should  not  be  borne  for  three  or  four  months. 

Whitman  states  that  reduction  under  anesthesia  by  rotation  and 
traction  of  the  fragments,  followed  by  fixation  in  abduction  with  a 
long  spica  plaster  bandage,  produces  the  best  results. 

The  advantage  of  abduction  is  that  it  makes  the  capsule  tense  and 
thus  aligns  the  displaced  fragments;  that  it  directs  the  surface  of  the 
outer  fragment  toward  that  of  the  inner;  that  it  relaxes  the  muscles  that 
produce  distortion  by  their  traction;  that  it  opposes  the  trochanter 
to  the  side  of  the  pelvis  and  thus  checks  upward  displacement.  Repair 
in  these  fractures  is  slow  and  can  hardly  be  completed  within  a  year; 
thus  prolonged  after-treatment  is  necessary  to  restoration  of  function 
1  J.  A.  M.  A.,  Feb.  20,  1909). 

(2)  Fracture  of  the  Shaft  of  the  Femur. — In  this  fracture  the    lower 


228  FRACTURES. 

fragment  is  nearly  always  displaced  forward  and  upward.  If  the 
fracture  has  been  produced  by  direct  force,  it  may  be  transverse,  but 
this  is  the  exception.  The  diagnosis  is  simple:  shortening,  eversion, 
loss  of  function. 

Manipulation  is  unnecessary  and  decidedly  to  be  avoided,  not  only 
that  the  patient  may  be  spared  the  pain,  but  also  that  the  trauma  may 
not  be  aggravated,  the  periosteum  torn,  the  muscles  bruised,  the 
vessels  injured. 

Reduction. — This  must  not  be  begun  till  all  the  dressings  are  quite 
ready.  Lay  the  patient  on  the  floor  or  on  a  hard  mattress  without 
pillows.  One  assistant  grasps  the  thigh  with  both  hands  near  the 
pelvis;  the  other  assistant,  the  foot  and  lower  third  of  the  leg.  As 
they  make  traction  and  countertraction  the  surgeon  manipulates  the 
fragments.  The  traction  must  be  prolonged  as  these  strong  muscles 
relax  only  gradually. 

When  the  fracture  is  quite  oblique  and  the  pointed  extremities 
are  caught  in  the  soft  parts,  a  little  patience  will  be  required  to  free 
the  fragments.  To  effect  this,  slight  rotation  and  oscillation  must  be 
added  to  extension  and  abduction. 

How  will  one  know  that  reduction  is  complete  ? 

(i)  These  points  must  exactly  correspond  when  the  two  limbs  are 
placed  side  by  side:  the  upper  border  of  the  two  patellae,  the  lower 
border  of  the  two  internal  malleoli,  the  two  soles. 

(2)  The  limbs  must  be  the  same  length  by  measurement  from  the 
anterior  superior  iliac  spine  to  the  inner  malleolus. 

(3)  The  line  dropped  from  the  iliac  spine  to  the  malleolus  must 
touch  the  inner  border  of  the  patelLe. 

Dressing. — Many  forms  of  splints  are  described;  many  of  them 
complex;  all  effective  in  some  degree.  Whatever  the  form  employed, 
the  limb  must  be  frequently  measured  and  the  patient's  general  con- 
dition kept  under  close  watch.  Scudder  highly  recommends  a 
modified  Buck's  extension  (Treatment  of  Fractures,  page  300,  et  seq.). 
Many  are  more  successful  with  the  plaster  cast. 

Lejars  recommends,  as  the  simplest  in  emergency  practice,  the 
dressing  of  Tillaux.  From  a  roll  of  adhesive  plaster  are  cut  eight  or 
nine  strips  one  and  one-half  inches  wide,  and  long  enough  to  extend 


TILT..\l\'s    DRESSING    FOB    FRA<   M  B I     0]     TEDS    FEMUR.  229 

from  the  level  of  fracture  down  the  side  of  the  limb,  over  the  sole  of  the 

fooi  after  the  manner  of  a  stirrup,  and  up  the  opposite  side  of  the  leg 
to  the  level  of  the  Fra<  lure. 

Begin  by  applying  one  of  the  strips  in  the  direction  indicated.  Next 
slip  a  strip  transversely  under  the  thigh,  another  under  the  calf,  and  a 
third  under  the  ankle,  and  make  one  circular  turn  of  each.  Next 
apply  a  second  longitudinal  strip  slightly  overlapping  the  first;  fol- 
low with  another  turn  of  each  circular  strip,  and  so  on.  In  this 
manner  the  strips  are  given  a  firm  attachment. 

Every  point  of  contact  of  the  adhesive  must  be  perfectly  smooth. 
Every  longitudinal  strip  must  extend  the  same  distance  as  its  fellows 
below  the  sole  in  order  that  the  extension  weight  shall  make  uniform 
traction  on  all  the  components  of  the  stirrup. 

A  cord  is  fastened  to  the  stirrup,  passed  through  a  pulley  at  the 
foot  of  the  bed  and  a  weight  of  five  to  ten  pounds  attached.  If  a 
pulley  is  not  obtainable,  a  hole  can  be  cut  in  the  foot  of  the  bed  if  it 
is  wooden;  or  the  cord  may  work  over  a  broom  handle  attached  to  an 
iron  bedstead.  The  weight  must  be  increased  in  the  case  of  the 
muscular  or  in  the  case  of  a  very  oblique  fracture. 

A  case  will  illustrate  the  difficulties  which  may  attend  reduction  in 
these  cases  of  fracture  of  middle  of  the  shaft.  A  young  man  caught 
and  crushed  under  a  falling  load  of  telegraph  poles  was  brought  to  the 
City  Hospital  in  full  shock.  It  scarcely  seemed  possible  for  him  to 
survive.  It  seemed  certain  that  he  must  have  had  grave  internal 
injuries  though  there  was  no  direct  evidence  to  that  effect.  The  shock 
gradually  subsided  and  no  further  evidence  of  visceral  complication 
arising,  attention  was  directed  to  his  fractured  femur,  which  was  broken 
about  the  middle.  Efforts  at  reduction  were  painless  but  wholly 
ineffectual  in  securing  a  coaptation.  Continuous  extension  was  ap- 
plied but  after  two  days  an  X-ray  examination  showed  the  fragments 
still  separated  and  overlapping. 

Later  an  open  operation  found  the  broken  ends  interlocked  with 
muscular  tissue.  With  some  effort  they  were  freed,  coapted  and 
wired.  Some  suppuration  delayed  repair,  but  he  finally  recovered 
with   a  good  limb. 

(3)  Supracondylar  fractures  derive  their  importance  from  the  Ere 


23° 


FRACTURES. 


quency  with  which  the  fragments  involve  the  knee  joint  or  the  struc- 
tures in  the  popliteal  space,  and  from  the  difficulty  of  maintaining 
coaptation.     Both   these   characteristics   depend   upon  the   obliquity 


Fig.  158. — Separation  of  epiphysis  of  lower  end  of  femur;  below  is  shown  the 
epiphysis  of  the  tibia  in  its  normal  relation. 

of  the  fracture  which  usually  extends  from  behind  downward  and 
forward.     The  complications  must  be  treated  on  general  principles. 

The  fixation  may  be  any  of  the  means  just  described  for  fractures 
of  the  shaft.  In  this  case  as  in  any  very  oblique  fracture,  flexion  of 
knee  and  hip  seem  specially  indicated. 


FRACTURE   in    nil     PATELLA.  231 

Hennequin's  apparatus,  which  Lejars  describes,  secures  an  effi- 
■ent  extension,  combined  \\  ith  Sexion  of  the  hip  and  knee  and  permits 
the  patient  to  sit  up.  Downey,  of  ( rainesville,  ( la.,  has  thought  out  a 
device  which  involves  the  same  principles  as  the  Hennequin  apparatus 
but  is  simpler  ill  application.  As  Downey  remarks  (Jour.  Am. 
Med.  Assn.,  Aug.  25,  [906)  the  dressing  aims  to  secure  at  once 
the  position  of  the  Esmarch,  Smith,  Hodgen,  or  Cabol  apparatus; 
the  extension  of  the  Buck  apparatus;  the  fixation  of  plaster  of  Paris. 
This  is  accomplished  by  means  of  a  double  angular  plaster-ol-l'aris 
splint. 

The  mode  of  application  (briefly)  is  this:  Secure  countertraction  by 
a  padded  sheet  passed  between  the  legs  and  brought  well  up  against 
the  perineum;  traction,  by  grasping  the  leg  above  the  ankle  with  one 
hand,  under  the  knee  with  the  other.  A  plaster  cast  is  applied  from 
the  toes  to  just  above  the  knee,  which  is  well  flexed.  Now  secure 
coaptation. 

Next  apply  the  second  section  of  the  cast,  beginning  at  the  upper 
border  of  the  first  and  carrying  the  roller  in  the  ordinary  manner  up  to 
the  ensiform,  all  the  while  maintaining  the  traction  with  hip  well 
flexed.  Strengthen  the  outer  side  of  the  cast  at  the  hip-joint  by  up-and- 
down  folds  of  the  roller  or  by  metal  splints.  Split  the  splint  if  con- 
st fiction  is  feared. 

Fracture  of  the  Patella. 

Fractures  of  the  patella  are  comparable  with  those  of  the  olecranon. 
They  may  be  transverse,  such  are  usually  fractures  resulting  from 
indirect  force;  or  they  may  be  vertical,  or  oblique,  or  multiple  (Figs. 
159,  160,  161). 

There  are  two  obstacles  to  osseous  reunion:  the  action  of  tin1 
quadriceps  extensor  and  the  intervention  of  the  patellar  fascias,  pre- 
venting exact  coaptation.  In  spite  of  these  unfavorable  circumstances, 
there  is  generally  some  form  of  fibrous  reunion  unless  the  fragments  are 
very  widely  separated  (Fig.  162). 

The  treatment  of  the  present  time  is  by  one  of  two  methods — mas- 
sage or  suture.  If  the  fracture  is  transverse,  with  very  little  separa- 
tion, and   the  conditions  are   not    favorable   for  an  aseptic  operation, 


232 


FRACTURES. 


massage  may  be  expected  to  give  a  good  functional  result.  If  the 
separation  is  considerable,  massage  will  still  give  a  better  result  than 
any  splints. 

In  any  case  suturing  is  the  ideal  form,  although  the  ideal  cannot 
always  be  attained.     Again,  every  compound  fracture  should  be  im- 


Fig.  159. — Transverse  fracture  of  the  patella. 

mediately  sutured.  J.  H.  Ford,  whose  experience  with  these  frac- 
tures has  been  large,  describes  his  method  of  procedure  in  ordinary 
fracture  (Ind.  Medical  Jour.,  July,  1907). 

In  the  non-operative  cases  he  begins  by  elevating  the  limb  for  several 
days  to  relax  the  quadriceps.     If  there  is  effusion  he  bandages  lightly 


FRACTURE    OF    TlIE    PAT  M.I.N. 


233 


with   a  flannel  roller,  or  if  the  bemarthrosis  is  marked,  a  firm  con- 
striction is  practised  or  ice-bags  applied. 


PlG.  160. — Transverse  frac- 
ture of  patella.     (Moullin.) 


Fir,.  161. — Comminuted  frac- 
ture of  patella.      (Moullin.) 


As  soon  as  the  acute  symptoms  have  subsided,  which  is  after  three 
to  five  days,  massage  is  instituted  and  daily  applied.  Begin  with 
gentle  constriction  of  the  joint  with 
the  hands  by  an  upward  movement, 
and  ending  with  more  vigorous  pres- 
sure of  the  sides  of  the  patella  and 
the  joint.  In  the  intervals  the  limb 
should  be  maintained  on  a  posterior 
splint.  After  from  four  to  six  weeks 
of  treatment,  he  immobilizes  the  joint 
in  a  plaster  cast,  preferably  for  two 
weeks  more,  and  subsequently  he 
recommends  a  morning  and  evening 
massage  and  flannel  bandaging  until 
the  functions  are  practically  restored. 

The  operative  treatment  is  by  no 
means  simple,  yet  by  no  means  beyond 
the  skill  of  anyone  Nvho  knoNvs  how  to 
secure  asepsis  and  to  apply  a  bone 
suture.  Begin  with  a  semilunar  inci- 
sion, concave  upward,  well  below  the 
line  of  fracture  and  reaching  to  either 
border  of  the  patella.  Raise  the  cut*-  SrS^rS^ 
neous    flap    and   expose    the    patella. 

The   articulation   is  carefully   wiped   out  and   freed  of  all   fragments 
and  clots. 


234 


FRACTURES. 


Fixing  the  upper  fragment  between  the  finger  and  thumb,  two 
slight  incisions  are  made  in  the  periosteum  at  the  points  where  the  drill 
is  expected  to  enter.  Two  tunnels  are  now  drilled  from  -above,  emerg- 
ing on  the  face  of  the  fracture  well  outside  the  line  of  the  cartilage. 
The  sutures  are  drawn  through  these  openings  and  the  process  is  re- 
peated in  the  lower  fragment,  but  great  care  must  be  used  in  securing 


Fig.  163. — Suture  of  patella.     MethocTof  drilling  and  passing  sutures.     (Labey.) 


a  correspondence  with  the  first  two  drill  holes  or  the  coaptation  will  be 
imperfect  (Fig.  163).  By  traction  on  the  sutures  the  fragments  are 
brought  together,  and  great  care  is  necessary  to  avoid  including  shreds 
of  fascia.  The  sutures  are  tied,  twisted  firmly,  and  pressed  down 
upon  the  bone.  The  periosteum  and  fibrous  coverings  are  next 
sutured  with  catgut  (Fig.  164). 


SUTl'Ki     OF    nil     PAT!  l  LA. 


*35 


Ford   prefers  not   to  wire,  but,  after  approximation,  sutures  the 
lateral    fascia  with    No.    3    forty  day    chromicized    catgut    and    the 

aponeurosis  in  front  with  No.  1.  A  No.  1  forty-day  suture,  18  inches 
long,  is  then  threaded  on  a  Strong,  half  curved  needle  which  is  entered 
into  the  aponeurosis  just  above  and  on  a  line  with  the  outer  edge  of  the 
patella  and  follows  the  upper  border  of  the  patella  to  the  inner  side 
where  it  emerges;  is  re  entered  and  carried  down  the  inner  side;  again 
around   the  lower  fragment,   passing  through  the  ligamentum   patella 


Fig.    16.1. — Suture  of  patella.     Completing  repair  by  suture  of  periosteum 
and  fibrous  coverings.     (Labey.) 


and  emerging  at  its  outer  border.  This  retention  suture  is  now  tied 
tightly  at  this  last  point  of  emergence  (Fig.  165).  The  skin  wound  is 
next  repaired  without  drainage.  The  limb  is  subsequently  immobil- 
ized for  two  weeks  when  massage  is  to  be  begun. 

Ford  lays  down  these  rules  respecting  the  treatment  of  simple 
transverse  fracture: 

(1)  Operative  treatment  should  never  be  undertaken  except  under 
the  best  conditions  for  maintaining  asepsis. 


236  FRACTURES. 

(2)  Even  under  aseptic  conditions  not  every  case  should  be  operated 
on,  but  only  those  in  which  the  separation  is  at  least  one-half  inch  and 
the  "reserve  extension  apparatus"  is  compromised  by  lateral  tears. 

(3)  Operative  treatment  fulfills  all  the  indications  in  a  degree  which 
the  non-operative  treatment  can  only  partially  achieve. 


Fig.  165. — Fracture  of  patella.     Circular  suture.     (Labey.) 

(4)  Early  massage  favors  complete  restoration  of  function  and 
should  be  used  in  all  cases. 

(5)  In  operative  treatment  open  arthrotomy  should  be  practised. 

(6)  Absorbable  suture  material  applied  only  to  the  soft  parts  is 
sufficient  in  nearly  every  case. 

FRACTURES  OF  THE  LEG. 

Fractures  of  the  leg  present  many  variations,  but  the  prognosis 
and  the  difficulties  of  treatment  depend  chiefly  upon  whether  the 
fracture  is  transverse  or  oblique.  If  transverse  there  is  usually  slight 
displacement,  easily  reduced  and  easily  maintained;  if  oblique  there 
may  be  much  displacement  which  is  difficult  to  reduce  and  hold,  and 
often  results  in  much  loss  of  function. 


!'KA(    I  I    Kl      ()!■      1111      III.. 


237 


Transverse  fractures  more  commonly  arc  due  to  direct  force  and 
the  lesion  corresponds  to  the  application  of  force.     Oblique  fractures 

are  more  commonly  due  to  indirect  force  and  the  two  bones  give  way  at 
their  point  of  least  resistance,  which  in  the  case  of  the  tibia  is  at  the 
■unction  of  the  middle  and  lower  third;  in  the  case  of  the  fibula  in  the 
upper   third.       In   general,  displacement   is 
always  favored  if  both  bones  are  fractured. 
The   diagnosis    of    these  injuries  usually 
offers  but  little  difficulty.     The  deformity, 
loss   of   function,    pain    and   crepitus,    and 
preternatural  mobility  leave  but  little  doubt 
except  when  the  injury  is  at  the  upper  end, 
and  where  the  joint  may  be  involved,  or  when 


PlO.  166. — Cloth  cut  to  fit  the  limb  ami  gore]  at  the  ankle  in  order  to  be  more  easily 
adjusted  to  the  malleoli  when  it  is  soaked  with  plaster.      (Lejars.) 


the  fibula  alone  is  fractured.  A  useful  test  for  fracture  of  the  fibula  is 
compression  of  the  two  bones  some  distance  from  the  suspected  site;  the 
pain  occurs  not  at  the  point  of  pressure  but  at  the  point  of  fracture. 

Reduction. — The  assistant  grasps  the  leg  at  the  knee,  the  surgeon  the 
foot,  seizing  the  foot  with  one  hand  and  the  heel  with  the  other;  or  two 
assistants  may  make  the  necessary  traction  while  the  surgeon  manipu- 
lates the  fragments. 

What  is  the  test  of  good  coaptation?  The  crest  of  the  tibia  forms  a 
continuous  line  without  projections  or  depressions.     This  line  pro- 


238 


FRACTURES. 


longed  strikes  the  first  metacarpal  space.  The  internal  surface  of  the 
tibia  is  smooth  and  uniform.  With  the  foot  at  a  right  angle,  a  line 
dropped  from  the  anterior  superior  iliac  spine  to  the  inner  border  of 
the  great  toe  touches  the  inner  border  of  the  patella. 

Dressing. — This  will  vary  somewhat,  depending  upon  the  situation 
and  tendency  to  displacement.     In  the  simple  case  of  fracture  of  the 


Fig.  167. — Plaster  splint  applied  and  fixed  with  roller  plaster  bandage.     Note  manner 
of   supporting  limb  and  applying  roller.      (Lejars.) 


shaft  of  the  tibia,  following  the  counsel  of  Stimson  (Fractures  and  Dis- 
location, page  381  et  seq.),  it  is  best  to  put  the  patient  to  bed  with  the 
limb  in  a  Volkmann  splint  for  about  a  week  until  the  swelling  has  sub- 
sided, and  then  to  encase  it  in  plaster  of  Paris.  Immediate  applica- 
tion of  the  plaster  of  Paris  is  objectionable  because  it  cannot  be  deter- 
mined from  the  first  whether  the  swelling  will  increase  or  diminish. 
The  two  dressings  may  be  combined  by  applying  a  plaster  splint  from 
the  first. 


I'l  \si  i  R    SPLINT    FOB    mi     LEG. 


239 


Lejaxs  describes  the  construction  of  such  a  splint.  He  measures 
from  the  middle  of  the  thigh  down  to  the  heel  and  up  the  sole  to  the 
toes,  and  this  will  be  the  length  of  the  sixteen  layers  of  crinoline  from 
which  the  splint  is  to  be  made.  Take  the  circumference  of  the  thigh, 
the  knee,  the  middle  of  the  leg,  the 
ankle,  and  transfer  the  measures  to 
the  crinoline  which  was  cut  wide 
enough  in  the  first  place  to  encircle 
the  thigh.  Connect  the  ends  of 
these  cross  measurements  with  a 
chalk  line  and  in  this  manner  one 
forms  a  rough  outline  of  the  limb, 
and  the  bandage  is  cut  accordingly. 
Some  prefer  to  apply  the  material 
to  the  sound  limb  and  mark  it  off 
in  that  way. 

Opposite  the  ankle  a  notch  should 
be  cut  in  the  dressing,  running 
toward  the  heel,  that  the  dressing 
may  be  more  readily  fitted  (Fig. 
166).  This  is  soaked  with  liquid 
plaster  and  applied  while  the  ex- 
tension and  counterextension  are 
maintained  and  the  foot  fixed  at  a 
right  angle.  This  tension  must 
not  be  relaxed  until  the  plaster  has 
hardened.  The  dressing  is  com- 
pleted by  applying  a  roller  bandage 
(Fig.  167). 

Oblique  fractures,  which  are 
hard  to  hold,  are  likely  to  be  near 
the  lower  end,  for  the  quadriceps 
extensor  pulls  the  upper  fragment 

forward,  and  the  gastrocnemius  pulls  the  lower  fragment  backward. 
The  special  form  of  dressing  which  Scudder  recommends  for  this  form 
of  fracture  is  made  by  a  combination  of  plaster  ami  adhesive  strips. 


Fig.  168. — Plaster  traction  splint:  a. 
Application  of  adhesive-plaster  extension 
strips;  (>,  plaster  bandage  allowing  exit  of 
extension  straps.  Note  space  left  below 
the  sole  to  allow  for  effective  traction  and 
buckles  to  which  the  upper  extension  is 
attached.      (Scudder.) 


240 


FRACTURES. 


The  adhesive  strips  are  applied  as  indicated  (Fig.  168).  A  thick  rod 
of  sheet  wadding  is  applied  to  the  sole  of  the  foot,  and  a  plaster  bandage 
applied  from  the  toes  to  above  the  knee.  A  buckle  looking  upward  is 
incorporated  in  the  plaster  just  above  the  level  of  the  knee.     A  slit  is 


Fig.  169. 


-Fracture  of  the  tubercle  or  anterior  tuberosity  of  the  tibia ;  point  of 
insertion  of  the  ligamentum  patellas. 


left  in  each  side  at  the  ankle  for  the  lower  extension  strips  to  come 
through.  When  the  plaster  has  hardened,  the  upper  extension  strips 
are  fastened  in  the  buckles  and  the  lower  extension  strips  pulled  out 
through  the  slits  and  drawn  tight  around  the  foot  piece  after  the  wad- 


POTT  S    FRACTURE. 


24] 


ning  al  the  sole  has  been  removed.     The  purpose  of  this  arrangement 
is  to  maintain  extension. 

Whatever  form  of  dressing  is  used  the  limb  must  he  watched  to 
see   that    DO  displacement   occurs.      While   a   simple   fracture   usually 


PlO.  1 70. — Pott's  fracture.     Fracture  of  the  fibula  and  of  the  internal  malleolus. 


firmly  unites  within  six  weeks,  those  which  have  been  hard  to  keep 
reduced  will  remain  weak  much  longer.     As  soon  as  there  is  sufficient 
union  to  prevent  displacement,  then  massage  should  be  begun  and  con- 
tinued till  the  limb's  functions  are  restored. 
16 


242  FRACTURES. 

Pott's  Fracture. — Fracture  of  the  fibula  with  eversion  and  ab- 
duction has  a  character  of  its  own.  As  Stimson  remarks,  the  diagnosis 
can  usually  be  made  at  a  glance  (Fig.  172).  Three  points  of  tenderness 
on  pressure  are  constant  and  characteristic:  one  in  the  groove  between 


Fig.  171. — Fracture  of  the  shaft  of  the  fibula.    Too  high  for  a  Pott's. 

the  tibia  and  external  malleolus;  another  at  the  base  of  the  internal 
malleolus;  the  third  over  the  outer  aspect  of  the  fibula  marking  the 
point  of  fracture.  Marked  ecchymosis  appears  beneath  the  external 
malleolus  and  sometimes  beneath  the  internal  (Figs.  170,  171). 


I'ol  I    S     1  K  All  I   R]  . 


243 


Reduction. — Grasp  the  foot  in  one  hand,  the  heel  in  the  other,  and 
while  ihr  leg  is  steadied  by  the  assistant,  draw  the  foot  forward  and 
inward.  If  this  does  not  entirely  succeed,  the  fragments  may  be 
pressed  into  place.  With  the  foot  at  a  right  angle  and  the  malleoli  in 
their  normal  relations,  the  dressing  is  applied.  This  dressing,  to 
quote  Stimsoo  further,  is  preferably  a  posterior  and  lateral  plaster 
splint  although  the  plaster  cast 
may  be  used. 

The  plaster  splint  may  be 
made  from  twelve  to  thirteen 
Layers,  cut  from  a  four-inch 
plaster  roller.  The  posterior 
splint  should  be  long  enough  to 
extend  from  the  toes  along  the 
sole  and  up  the  calf  nearly  to 
the  knee  (Fig.  173).  The 
lateral  one  should  begin  just  in 
front  of  the  external  malleolus, 
pass    over    the    dorsum   of   the 

foot  to  the  inner  side,  under  the  whole  and  up  along  the  outer  side  of 
the  leg  to  the  same  height  as  the  posterior  (Fig.  174).  They  are 
snugly  molded  and  bound  to  the  limb  while  still  wet,  with  a  roller 
bandage. 

In  the  meantime,  till  the  plaster  sets,  the  reduction  must  be  main- 
tained. 

Dupuytren's  splint  is  often  of  great  service  in  this  fracture,  especially 
as  a  temporary  dressing.  It  consists  of  internal  lateral  splint,  well 
padded  over  the  ankle  and  which  extends  from  above  the  knee  and 
projects  beyond  the  foot.  It  is  held  in  place  by  a  bandage  at  the  knee 
and  above  the  ankle.  The  foot  is  then  put  in  abduction  at  right  angles 
to  the  leg  and  secured  to  the  splint  by  a  third  bandage  (Fig.  175). 


PlG.  173.  —  Pott's   fracture. 


FRACTURE  OF  THE  SCAPULA. 

Fracture  of  the  neck  of  the  scapula  might  be  mistaken  for  fracture 
or  dislocation  of  the  humerus  (Fig.  176).     The  head,  however,  can  be 


244 


FRACTURES. 


Fig.   173. — Posterior  splint  applied. 
(Stimson.) 


Fig.  174. — Lateral  splint 
applied.      (Stimson.) 


Fig.   175. — Dupuytren's  splint.     Temporary  dressing  forjPott's  fracture. 


I  k  M   I  I  R]     01     l  in.   SCAP1  l  \. 


245 


felt  to  rotate,  which  it  would  not  do  in  dislocation.     The  deformity 

disappears  on  lifting  the  arm  forcibly  upward  with  the  elbow  Hexed, 

which  docs  not  happen  in  a  case  of 

fracture  of  the  humerus;    the  arm 

hangs  vertically  at  the  side  and  is 

mobile.     There  is  no  notching  of 

the  deltoid. 

In  the  case  of  fracture  of  the  sur- 
gical neck  of  the  humerus  with  over- 
riding, the  arm  is  shortened.  In 
case  of  fracture  of  the  scapular  neck, 
the  arm  is  lengthened. 

Generally  speaking,  the  diagnosis 
of  any  fracture  of  the  scapula  is  to 
he  made  from  crepitus,  abnormal 
mobility,  local  tenderness,  and  more 
or  less  complete  loss  of  certain 
functions.  Begin  the  examination  by  inspection  and  measurement. 
Note  any  loss  of  contour;  any  lengthening  or  shortening  of  arm.  To 
elicit  crepitus,  apply  one  hand  to  the  body  of  scapula  and  with  the 
other  make  traction  on  the  arm.  In  thin  subjects  the  lower  end  of 
the  scapula  may  be  readily  grasped. 

Treatment. — The  flexed  elbow  should  be  well  supported  by  a  sling, 
and  the  arm  fixed  at  the  side.  Massage  will  relieve  the  pain  and 
hasten  repair.     Mayor's  sling  furnishes  an  excellent  dressing. 


Fig.   176.- 


Fracture  of  the  neck  of    the 
scapula. 


FRACTURE  OF  Till:  PELVIS. 


Fracture  of  the  pelvis  may  be  suspected  from  the  character  of  the 
injury,  which  is  usually  a  fall  or  a  crush.  The  diagnosis  is  to  be  con- 
firmed by  external  palpation  of  the  ilium,  pubes,  and  ischium  on  each 
side,  and  by  careful  rectal  and  vaginal  examination.  Disturbance  of 
normal  relations,  tenderness  on  pressure,  crepitation  perhaps,  and 
difficulty  in  walking  indicate  fracture  (Fig.  177). 

The  treatment  in  uncomplicated  cases  is  quite  simple,  rest  in  bed 
and  some  kind  of  pelvic  immobilization  such  as  adhesive  strapping. 


246 


FRACTURES. 


represent  the  elements  of  relief.     It  is  quite  different  if  there  are  com- 
plications. 

If  a  catheter  cannot  be  passed  (and  this  should  always  be  tried), 
it  will  be  necessary  to  do  an  external  urethrotomy  for  the  ruptured 
urethra.  If  the  catheter  finds  the  bladder  empty  and  ruptured,  a  lap- 
arotomy is  imperative.     If  the  exact  complications  cannot  be  deter- 


Fig.  177. — Fracture  of  the  pelvis  through  the  obturator  foramen  and  dislocation 
at  the  sacroiliac  joints.      (Moullin.) 

mined  and  yet  shock,  pain,  and  increasing  abdominal  tension,  with 
signs  of  sepsis,  point  to  a  lesion  of  bladder  or  rectum,  the  abdomen 
must  be  opened,  and  the  visceral  injury  found  and  repaired. 

Following  a  variety  of  traumatisms  there  is  often  a  condition  now 
well  recognized  as  relaxation  of  the  sacro-iliac  synchondrosis  which 
simulates  fracture  and  which  may  become  quite  chronic.  It  is  re- 
lieved by  adhesive  strapping. 


COMPOUND  FRACTURES. 

Every  compound  fracture,  whether  the  skin  wound  be  large  or  small, 
increases  the  danger  over  simple  fractures,  both  with  respect  to  function 
and  even  life. 


i  Ki  \l\li  NT   OF   COMPOUND    FRACTURES. 


247 


The  outcome,  as  has  so  often  been  said,  depends  largely  on  the  first 
treatment.  The  indications  are  various  and  depend  upon  the  amount 
of  fragmentation,  the  degree  of  destruction  of  the  soft  parts  and  the 
injury  to  the  blood  vessels. 

It  is  necessary  to  divide  these  injuries  into  several  clinical  groups. 
(Sec-  I. e jars.  Chirurgie  d'Urgence,  p.  1017  ct  sec].) 

1.  Compound  comminuted  fracture  with  no  injury  to  the  vessels,  with 
slight  injury  to  the  soft  parts,  and  small  skin  wound  is  most  commonly 
seen  in  oblique  fractures  of  the  tibia  (Fig.  178).  The  break  in  the  skin 
skin  is  slight  and  yet  it  is  actual  and  must  be  regarded  as  infected. 


Fig.  178. — Compound  fracture  of  tibia.     (Moullin.) 


Do  not  be  satisfied  with  merely  washing  the  skin  or  applying  a 
simple  occlusive  dressing.  This  may  be  sufficient  in  the  case  of  gun- 
shot wounds;  the  circumstances  may  permit  of  no  further  treatment: 
and  many  cases  will  get  well  with  nothing  more,  but  that  is  significant 
of  only  one  thing — that  by  good  luck  the  wound  was  not  inlet  ted. 
Whether  the  wound  is  or  is  not  infected,  one  can  never  tell.  He  must 
await  the  eventualities.  Therefore,  that  chance  may  not  enter  in,  one 
must  exercise  the  same  care  as  if  he  were  certain  the  germs  were  there. 
A  general  anesthesia  is  usually  not  necessary.  Begin  by  carefully  ster- 
ilizing the  surface  about  the  wound.  Scrub  with  soap  and  water, 
wa>h  with  ether  and  then  with  alcohol  and  finally  with  bichloride. 
Enlarge  the  wound  sufficiently  that  it  may  be  irrigated  with  hot 
sterile  water  or  normal  salt  solution.  Carefully  clear  out  all  debris 
with  as  little  injury  as  possible  to  all  the  tissues  concerned.      When  the 


248  FRACTURES. 

cleaning  is  complete,  if  circumstances  are  favorable,  the  wound  is 
sutured  and  drainage  employed.  Occasionally,  it  may  be  closed 
completely  without  drainage.  Sometimes  it  must  be  left  wide  open, 
packed  with  sterile  gauze  and  bandaged. 

Adjustment  and  Immobilization. — Reposition  requires  great  care  and 
it  must  be  exact.  Unless  the  fragments  are  extremely  difficult  to  hold 
in  place,  requiring  wiring,  the  limb  may  be  immobilized  with  a  plaster 
splint,  leaving  an  opening  sufficient  for  the  inspection  of  the  wound. 

Gangrene  is  little  to  be  feared  unless,  indeed,  the  bandages  are  care- 
lessly applied,  interfering  with  the  circulation. 

Immobilization  is  the  best  method  for  relieving  pain.  Carry  out  a 
careful  disinfection,  a  careful  adjustment  of  the  fragments,  a  careful 
immobilization  in  a  good  position,  and  one  may  confidently  expect  in 
such  cases  an  excellent  result. 

2 .  Compound  Fracture  with  much  Comminution  and  Great  Destruction 
to  the  Soft  Parts,  Little  Injury  to  the  Blood  Vessels. — A  general  anesthesia 
will  be  necessary.  Prepare  the  field  as  before  and  flush  out  the  wound 
cavity  with  hot  sterilized  water.  Trim  away  the  fragments  of  fascia 
and  muscle,  but  in  this  do  not  be  too  radical.  Such  of  these  shreds 
as  retain  their  blood  supply  can  help  later  to  fill  the  wound.  Especially 
do  not  remove  with  too  free  a  hand  the  fragments  of  the  bone.  Only 
such  fragments  as  are  completely  isolated  and  deprived  of  their  peri- 
osteum are  to  be  extracted  so  that  later  they  may  not  play  the  part  of 
foreign  bodies  (Fig.  179).  Lowery,  of  Carbondale,  injects  the  cavities 
with  a  mixture  of  carbolic  acid  95  per  cent,  and  glycerine  5  per  cent., 
following  this  with  alcohol.  A  glass  syringe  is  used,  and  the  aim  is 
to  force  the  solutions  into  the  deepest  recesses  of  the  wound  (J.  A.  M.  A., 
Oct.  31,  1909). 

The  second  step  consists  of  reposition  and  adjustment,  often  with 
difficulty  accomplished  and  many  times  requiring  wiring  or  suturing. 
The  wound  may  be  sutured,  but  must  be  drained.  More  important 
even  than  accurate  coaptation  in  these  cases  is  continuous  extension; 
for  that  reason  the  fixation  dressing  must  be  given  special  attention. 
If  no  fever  arises,  leave  the  dressing  undisturbed  for  eight  to  ten  days. 
The  danger  from  infection  is  then  passed  and  the  immobilization  and 
extension  may  be  continued  as  long  as  necessary. 


TRKATMIA'T    <>K    <  <  >\l  l'<  >l   \  I  >     I  K.\(    11   K I  S. 


249 


3.  Compound  Fracture,  Obviously  Infected. — You  see  the  case  per- 
haps some  days  after  the  injury.  It  has  been  neglected.  Marked 
Inflammation  is  present.  You  are  confronted  by  the  possibilities  of 
phlegmon  or  tetanus.  These  may  develop  with  the  greatest  rapidity 
and  continue  uninterruptedly  to  death. 

How  shall  one  act  in  the  presence  of  these  filthy  or  already  infected 
or  inflamed  fractures?     To  amputate  would  have  been  in  pre-antiseptic 


Fig.  179. — Compound  fracture  and  dislocation  at  the  wrist.     Hand  saved.     (Scudder.) 


days  the  proper  procedure,  but  not  to-day  and  especially  not  in  the 
recent  case. 

Enlarge  the  wound  freely.  Remove  the  coarsest  dirt  by  irrigation 
and  then  patiently  and  pirseveringly,  wiping  with  sterile  compresses 
while  flushing,  complete  the  toilet  of  the  individual  tissues,  one  at  a 
time.  The  fragments  of  bone  must  be  separated  and  the  remotest 
nook  of  the  wound  sought  out,  that  the  cleansing  may  be  complete. 
Do  not  spare  time  or  patience.  If  the  projecting  fragment  of  bone  is 
saturated  with  dirt,  manifestly  devitalized,  resect  it,  not  transversely, 


250  FRACTURES. 

however,  after  the  manner  of  an  amputation,  but  following  some  type 
of  plastic  operation  which  will  diminish,  as  much  as  possible,  the  loss 
of  bone  and  consequent  shortening  of  the  limb. 

Finally  the  wound  is  flushed  with  peroxide  of  hydrogen  and  wrapped 
with  sterile  gauze  saturated  with  the  same  solution.  With  the  frag- 
ments coapted  as  much  as  may  be  by  simple  manoeuvres,  though  one 
cannot  hope  to  achieve  much  in  this  respect,  the  drainage  is  applied 
and  must  be  ample.  The  limb  is  put  at  rest,  and  with  anxiety  the  out- 
come is  awaited.  The  issue  may  be  fortunate.  General  and  local 
infection  may  be  successfully  combated  and  later  the  bone  union  may 
be  secured. 

On  the  other  hand,  should  general  infection  be  imminent  or  gangrene 
ensue  or  the  limb  be  from  the  first  manifestly  destroyed,  there  is  no 
choice  but  to  amputate. 

COMPOUND  FRACTURE  ABOUT  THE  ANKLE 
AND  FOOT. 

Fractures  of  this  variety  are  frequent;  always  serious;  and  the  prog- 
nosis more  or  less  uncertain,  depending  upon  the  degree  of  infection 
and  destruction  of  the  soft  parts. 

Suppose  a  fracture  of  the  inner  malleolus:  the^oft  parts  are  widely 
separated,  the  joint  cavity  exposed,  the  astragalus  dislocated.  Such 
an  injury  must  be  as  conservatively  treated  as  an  abdominal  wound. 
Under  no  circumstances  must  the  wound  be  explored  with  unclean 
fingers  or  without  careful  cleansing  of  the  field.  Only  after  all  the 
preparations  for  definite  treatment  are  made  is  the  wound  to  be  ex- 
amined. If  transportation  is  necessary,  a  temporary  splint  is  pro- 
vided, but  at  least  do  not  cover  the  wound  with  a  dirty  handkerchief. 
If  there  is  much  hemorrhage,  circular  constriction  of  the  leg  about  the 
knee  will  temporarily  suffice. 

The  first  dressing  will  determine  the  future  of  the  limb,  perhaps 
even  the  life  or  death  of  the  wounded.  The  whole  foot  and  the  lower 
half  of  the  leg  are  most  carefully  disinfected  and  the  fracture  and  joint 
cavity  irrigated  with  hot  sterile  water,  exposing  every  nook  and  corner 
in  order  to  flush  out  foreign  bodies,  splinters  of  bone  and  clots  of   bl  ( c 


TREATMENT   OF   COMPOUND   FRA<  I  I  RES.  25 1 

In  this  case,  merely  chosen  for  example,  the  destruction  of  tissue  is 
unusually  light.  After  the  cleansing,  replace  the  parts,  leave  one  or 
two  drains  in  the  partly  sutured  wound,  bandage  amply  and  place  the 
limb  at  rest. 

The  situation  is  less  simple  where  there  is  much  destruction  of  tissue, 
as  in  the  case  where  the  ankle  is  crushed. 

Begin  with  hot  irrigations.  Do  not  fear  to  enlarge  the  wound  freely. 
It  is  of  great  importance  that  one  be  able  to  determine  definitely  the 
conditions  in  the  wound  and  to  see  what  he  is  doing. 

You  may  find  large  fragments  deformed  and  overlapping.  Try 
to  replace  them  and  often  you  will  be  thus  enabled  to  restore  the  con- 
tour of  the  joint.  To  retain  these  fragments,  wiring  or  nailing  the 
fragments,  if  in  a  position  to  carry  it  out,  will  be  an  almost  indispen- 
sable aid. 

Another  case:  The  epiphyses  are  reduced  to  fragments  of  various 
sizes  and  forms.  In  irrigating,  they  flow  away  with  the  solution,  so 
loosened  are  they.     The  rest  hang  by  a  mere  shred. 

Reposition  is  here  useless.  The  wreck  is  too  great.  You  must 
proceed  to  do  an  atypical  resection.  Do  your  best  to  spare  the  malleoli 
or  at  least  two  processes  which  will  serve  to  prevent  lateral  dislocation 
when  the  joint  is  healed. 

After  this  operation  insert  two  drainage-tubes,  one  on  either  side ;  and 
if  there  is  considerable  oozing,  add  an  aseptic  tamponade. 

The  prognosis  is  worse  if  infection  lias  developed  and  there  is  fever, 
redness,  and  swelling  in  the  limb.  Amputation  will  be  the  measure  of 
last  resort  and  yet  do  not  amputate  until  free  opening  has  again  been 
tried.  Irrigate  with  peroxide.  The  removal  of  dead  bone,  etc.,  is 
followed  by  deep  drainage  but  this  must  be  done  without  delay.  It 
is  not  union,  or  consolidation,  or  function  of  the  limb  which  is  the  chief 
concern.  It  is  infection  against  which  all  the  forces  of  antisepsis  are 
marshalled. 

Osteomyelitis  or  myelitis  is  the  contingency  feared.  In  such  a  case, 
do  not  employ  a  typical  amputation  or  resection,  but  an  atypical  one, 
removing  only  such  tissues  as  must  be  removed,  and  later  when  the 
infection  has  disappeared,  the  necessary  operations  may  be  done. 


CHAPTER  XIV. 
INJURIES  TO  JOINTS. 

Dislocations;  Compound  Dislocations;  Open  Wounds; 
Contusions;  Sprains. 

DISLOCATIONS. 

Shoulder-joint. — Of  all  the  joints,  the  shoulder  is  by  far  the  most 
frequently  dislocated.  Of  these  dislocations,  there  are  several  forms, 
and  yet  only  one  variety  is  likely  to  be  met  with  by  the  general  practi- 
tioner— the  sub-coracoid.  A  clear  conception  of  the  conditions  and 
of  the  manoeuvres  necessary  to  a  reduction  presupposes  a  very  definite 
notion  of  the  anatomy  of  the  joint. 

Recall  the  relation  of  the  acromion  and  coracoid  processes  to  the 
glenoid  fossa,  to  the  head  of  the  humerus  and  to  the  capsular  liga- 
ment; the  relation  of  the  long  head  of  the  biceps  to  the  joint  and  the 
attachments  and  actions  of  the  various  muscles  surrounding  the  joint, 
particularly  the  sub-scapularis,  the  spinati,  the  pectoralis  major;  and 
the  relations  of  the  axillary  vessels  and  nerves. 

However  simple  a  case  may  appear,  do  not  begin  any  manoeuvre 
until  a  complete  diagnosis  has  been  made. 

Diagnosis. — Begin  by  inspection.  The  patient  is  in  evident  pain; 
his  head  is  inclined  to  the  injured  side  and  he  supports  the  injured 
member  with  the  other  hand;  the  shoulder  is  flattened,  the  rounded 
prominence  of  the  deltoid  has  disappeared  and  the  acromion  projects; 
the  elbow  is  abducted  and  the  patient  is  unable  to  bring  it  down  to  the 
side. 

Palpation  reveals  the  axis  of  the  humerus  pointing  to  the  middle  of 
the  clavicle;  the  examining  finger  can  be  pushed  under  the  acromion 
where  the  humeral  head  should  be.  The  humeral  head  itself  may  be 
felt  below  or  to  the  inside  of  the  coracoid,  and  rotates  with  slight 
rotation  of  the  arm. 

252 


ki.ih  rnoN    «'i     1 111     siloi  ii'i  B  JOINT.  253 

The  fingers  in  the  axillary  spate  feci  the  rounded  head  of  the  hu- 
merus projecting  inward  more  noticeably  when  the  arm  is  slightly 
Abducted. 

This  question  arises:  "Is  ii  a  case  of  simple  dislocation,  or  is  it 
complicated  by  a  fracture  of  the  upper  end  of  the  humerus,  of  the  great 
tuberosity,  or  the  rim  of  the  glenoid  fossa?"  ''Have  the  arteries  or 
nerves  been  injured?"  You  must  test  particularly  for  laceration  of 
the  circumflex  nerve.  Do  this  by  pin  pricks  over  the  deltoid;  if  the 
skin  is  insensitive,  forecast  paralysis  and  atrophy  of  the  deltoid,  and  thus 
anticipate  and  disarm  censure. 

Reduction. — (Lcjars.)  The  method  of  Kocher  seldom  fails,  if 
properlv  applied,  and  if  the  various  movements  are  modified  to  suit 
the  individual  ease.  Its  purpose  is  to  put  the  head  of  the  humerus  in 
the  position  at  which  it  left  the  capsule.  Through  the  relaxed  tear  the 
head  is  then  to  be  levered  into  the  socket. 

Seat  the  patient  in  a  chair  facing  a  little  to  one  side.  Let  a  strong 
and  able  assistant,  standing  behind,  seize  the  patient's  shoulder  firmly 
and  make  pressure  downward  and  backward.  Place  yourself  before 
the  dislocation,  and  seizing  (in  the  case  of  the  left  arm)  the  forearm  at 
the  el  I  iow  with  the  left  hand,  and  the  wrist  with  the  right  hand,  direct 
the  patient  to  hold  the  head  up  and  look  straight  ahead. 

First  Stage:  l-'lc.xion,  Adduction. — The  elbow  is  flexed  and  then 
gradually  adducted  until  it  touches  the  body,  the  wrist  held  firmly 
meanwhile.  The  elbow  is  now  pushed  backward  beyond  the  axillary 
line — the  first  stage  is  not  complete  without  this.  Neglecting  this  part 
of  the  first  manoeuvre  is  a  frequent  cause  of  failure.  Do  not  get  in  too 
gnat  a  hurry.  Remember  that  the  larger  part  of  the  resistance  is  due 
to  the  muscles  and  that  they  yield  only  gradually.  Too  sudden  and 
too  violent  traction  on  them  augments  the  pain  and  their  resistance. 
To  pause  a  little  now,  gives  them  time  to  relax  (Fig.  180). 

Second  Stage:  External  Rotation.— Hold  the  elbow  fast  and  flexed 
at  a  right  angle,  and  now  with  your  right  hand,  swing  the  forearm 
outward  and  backward  until  it  lies  in  the  transverse  vertical  plane 
of  the  body  (Fig.  iS  1  I.  Its  axis  lies  directly  in  front  of  you.  Perform 
the  manoeuvre  cautiously  and  smoothly.  Again  pause  until  the  mus<  les 
are  relaxed.      Do  not   be  alarmed   by   the  snapping  distinctly   heard 


254 


INJURIES   TO   JOINTS. 


in  the  movement.  One  may  follow  the  movement  of  the  bulging  head 
of  the  humerus  with  the  eye.  Occasionally  reposition  occurs  at  the' 
end  of  this  movement,  if  it  has  been  carried  out  methodically,  or  at  J 
least  at  the  beginning  of  the  third  stage. 


Fig.^i8o. — Reduction  of  shoulder.    First  stage  :    Flexation  ;  adduction;  elbow  a 
little  posterior  to  the  axillary  line. 

Third  Stage:  Elevation. — Maintaining  flexion  and  external  rotation, 
next  lift  the  elbow  upward  and  forward — upward  and  forward  exactly 
— do  not  permit  the  elbow  to  move  outward.     Abduction  will  spoil  the 


R]  in  (i  [ON    01     i  hi     sum  LDEB   rOINT. 


255 


manoeuvre  (Fig.  182).  Lift  upward  and  forward  till  the  arm  reaches 
the  horizontal — a  sudden  snap  indicates  that  the  head  has  slipped  into 
the  socket. 


Pig.  1 8  > .     Reduction  of  shoulder.    Second  stage:   External  rotation  until  fore- 
arm stands  at  ri^'ht  ai.Rle  to  body 

Fourth  Stage:  Inter/ml  Rotation. — Proceed  now  rapidly  to  swing  the 
forearm  inward  and  across  the  chest  until  the  hand  rests  on  the  oppo- 
site shoulder  (Fig.  183).  The  movement  is  made  rapidly  hut  with  no 
great  force.     This  latter  holds  good  with  respect  to  all  the  movements. 


256 


INJURIES    TO   JOINTS. 


It  must  be  observed  that  the  surgeon's  hands  do  not  change  their  hold 
at  any  stage  of  the  reduction. 

If  these  manoeuvres  fail,  repeat  them  in  the  same  order,  using  a  little 


Fig.    182. — Reduction  of  shoulder.     Third  stage:   Elevation  while  maintaining 
external  rotation. 

more  force  in  the  second  and  third  stages  and  pausing  a  little  longer 
at  the  end  of  a  stage. 

In  the  sub-clavicular  form  also  this  manoeuvre  will  succeed,  but 
should  be  modified  to  this  extent:  prolong  the  second  stage  two  or 


ki  hi  CTION    OP    mi     SHOU1  in  B  JOIN  r. 


257 


three  minutes,  using  more  force  to  obtain  external  rotation  and  the 
backward  position  of  the  elbow.  In  this  wise,  the  muscles  arc  re- 
laxed more  completely.  Without  changing  the  external  outward  ro- 
tation, the  elbow  is  lilted  upward  and  forward  as  before 


Pig.  183.— Reduction  of  shoulder.     Fourth  stage.     Internal  rotation. 

Not  less  efficient  in  certain  cases  of  sub-coracoid  dislocation  is  the 
method  of  Mothe,  or  traction  in  extreme  abduction.  It  is  also  applicable 
in  all  other  forms  of  inward  and  downward  dislocation. 

In  this  procedure,  COUnterextension  is  indispensable.  A  long  towel 
*7 


258 


INJURIES    TO   JOINTS. 


will  serve.  It  encircles  the  injured  shoulder,  passing  under  the  arm- 
pit, and  the  two  ends  cross  the  back  toward  the  sound  side.  While  the 
assistant  makes  forcible  counter-extension,  the  operator  manipulates 


Fig.  i  34. — Reduction  of  shoulder.     Traction  with  high  abduction.     The  axis  of  the  humerus 
should  be  in  line  with  the  spine  of  scapula.     Assistant  steadies  the  shoulder. 


the  arm.  It  is  best  that  he  stand  on  a  stool  or  chair  if  not  tall  enough 
to  make  good  traction  upward.  Now  seize  the  arm  above  the  elbow 
and  the  forearm  near  the  wrist  (Fig.  184).  Flex  the  elbow.  Next 
elevate  the  arm  by  extreme  abduction  until  it  is  in  line  with  the  spine 


REDUC1  [ON    01    l  Hi     SHOULD!  B  JOINT. 


259 


of  the  scapula.  The  arm,  you  must  observe,  does  not  reach  the 
horizontal  merely,  it  is  elevated  beyond  thai  level.  This  is  <>|  the 
greatest  importance.  With  the  arm  thus  in  extreme  abduction,  next 
nake  strong  traction  in  thai  direction  (Fig.  [85).  Assistance  in  trac- 
non  may  be  necessary;  or  one  may  confide  the  traction  to  an  assistant, 


1S5      Reduction  by  high  abduction  and  traction.     Mote  manner  in  which  the  assistant 

steadies  the  she  irs.) 


while-  with  the  thumbs,  one  pushes  against  the  humeral  head  in  the 
axillary  space. 

If  this  docs  not  succeed,  begin  the  second  stage: 

Depress  the  arm  rapidly  and  smoothly.  Letting  the  point  of  the 
clliow  pass  in  front  of  the  chest,  all  the  while  maintaining  traction. 
This  method  occasionally  fails  for  these  reasons: 


260  INJURIES    TO   JOINTS. 

(i)  Traction  with  high  abduction  is  not  long  enough  continued. 
The  arm  is  depressed  before  the  head  has  been  sufficiently  elevated  by- 
traction. 

(2)  The  arm  is  lowered  too  slowly. 


Fig.  186. — Chipman's  method  of  reducing  dislocated  shoulder.     First  stage. 
(International  Journal  of  Surgery.) 

In  neglected  cases  or  in  the  very  muscular,  general  anesthesia  may 
be  indispensable  whatever  the  method,  but  force  must  then  be  em- 
ployed with  still  greater  care,  and  it  must  be  borne  in  mind,  too,  that 
incomplete  anesthesia  here  is  as  dangerous  as  it  is  useless.     The  par- 


ri  m  <   i  ion    or   Till     SHOl  I  Dl  R  JOINT. 


.:<>\ 


■cular  danger  of  this  method  is  laceration  of  the  axillary  structures. 
If  general  anesthesia  is  strongly  contraindicated,  local  anesthesia  may  be 
Employed,  injecting  the  joint  and  the  tendons  near  their  lines  of  inser- 
tion.     How  long  after  the  injury  reduction  may  be  attempted   cannol 


^^^r^                              ^^^B 

■ ;• 

* 

Imc.  i  S7.     Cliipman's  method  of  reducing  dislocated  shoulder.      Second  stage. 
{International  Journal  of  Surgery.) 

he  determined  by  any  rule,  hut  by  the  conditions  in  the  individual  ease. 
Chipman,  of  New  London,  Connecticut,  suggests  a  method  which 
mii-l  prove  of  value,  especially  to  the  doctor  compelled  to  act   without 
assistance. 


262 


INJURIES    TO   JOINTS. 


He  describes  his  method  thus  (Int.  Journal  of  Surgery,  November, 
1906):  Stand  facing  your  patient.  Gradually  raise  the  dislocated 
arm  to  a  horizontal  position  and  place  it  on  your  shoulder  with  forearm 
flexed  on  your  back.  Direct  the  patient  to  pass  the  well  arm  under 
your  arm  and  grasp  the  wrist  of  the  injured  arm  with  the  well  hand. 
Thus  the  patient's  arms  encircle  your  body,  the  injured  one  passing 
over  one  shoulder,  the  sound  passing  under  the  other  (Fig.  186). 

Second  Stage. — Now  direct  the  patient  to  sag  downward,  and  the 
weight  of  the  body  drags  the  head  of  the  humerus  outward  and  up- 


Dislocation  of  shoulder.      (Walsham.) 


ward,  when  you  can  easily  return  it  to  the  glenoid  cavity  with  your 
hands  (Fig.  187).  The  dislocation  is  so  easily  and  expeditiously  re- 
duced that  even  the  surgeon  himself  is  surprised.  There  is  the  least 
possible  additional  injury,  the  least  possible  pain;  there  is  no  need  of  an 
assistant  or  an  anesthetic. 


SUB-GLENOID  DISLOCATION. 

This  variety  is  always  the  result  of  forcible  abduction  of  the  humerus, 
the  tear  in  the  capsule  falling  below  the  glenoid  cavity,  and  the  head 
of  the  humerus  remaining  fixed  there  (Fig.  188). 

The  diagnosis  is  to  be  made  from  the  symptoms  already  described 
for  the  sub-coracoid  form,  the  only  difference  being  that  the  elbow 


ki  mi   i  [( »N    0]    -i  B  <•!  i  MOID    DISLOCA  flON. 


263 


is  further  from  the  chest,  the  flattening  of  the  shoulder  more  pro- 
nounced, the  luad  of  the  humerus  more  readily  felt  in  the  axilla 
Eg.   [89). 


Pig.  189.— Reduction  of  a  subglenoid  dislocation.     Second  stage.     Gradual 
elevation  with  constant  traction. 


The  reduction  may  be  affected  by  BLocher's  method,  but  perhaps 
tin-  best  method  is  that  of  extreme  abduction  with  traction,  which  has 
already  been  described.  The  patient  may  be  seated,  bul  often  must 
recline,  for  the  weight  of  the  pendent  limb  may  be  very  painful.     The 


264 


INJURIES    TO   JOINTS. 


injured  member  is  grasped  above  the  elbow  with  one  hand,  below  the 
wrist  with  the  other,  flexed,  slowly  raised  to  form  an  obtuse  angle  with 
the  chest.     In  this  position  strong  traction  and  countertraction  are  to 


Fig. 


190— Reduction  of  sub-glenoid  dislocation.     Third  stage.     Traction  with 
high  abduction  and  pressure  on  the  humeral  head. 


be  made.  Usually  this  succeeds,  though  it  may  help  to  press  the  head 
into  place  (Fig.  190).  If  traction  and  pressure  are  not  sufficient  to 
effect  reduction  after  the  muscles  have  been  thoroughly  relaxed,  the 
arm  is  to  be  depressed  as  before  described. 


\i  i  i  R   iki  \  I  \li  N  r   OF   SHOULDER    DISLOCATION.  265 

Sub  spinous  Dislocation. — In  this  case  the  shoulder  is  flattened  in 

fronl  and  the  examining  linger  finds  a  marked  depression  between  the 
tip  of  the  acromion  process  and  the  coracoid.  The  elbow  is  carried 
slightly  forward  and  the  arm  rotated  inward.  The  head  of  the  hu- 
merus can  he  felt  below  the  spine  of  the  scapula. 

Reduction.-  General  anesthesia  is  usually  necessary.  Grasp  the 
arm  above  the  elbow;  slightly  abduct  the  arm;  slightly  increase  the 
inward  rotation  (never  rotate  outward);  make  traction  in  a  direction 
downward   and    forward.      Pressure   forward  on   the  head   is  helpful. 

AFTER-TREATMENT    OF    SHOULDER    DISLOCATIONS. 

The  task  in  any  form  of  dislocation  does  not  end  with  reduction. 
There  is  still  the  duty  to  restore  usefulness  as  completely  as  possible, 
and  to  that  end  the  subsequent  care  must  be  minutely  regulated.  The 
inclination  is  to  immobilize  the  joint  too  completely  and  too  long, 
fearing  a  recurrence  of  the  dislocation.  This  enforced  rest  combined 
with  injury  is  liable  to  produce  atrophy  of  the  muscles,  stiffness  of 
the  joint,  and  protracted  loss  of  function.  The  indications  for  after- 
treatment  arc  vari  ;us,  depending  upon  clinical  conditions. 

(A)  An  uncomplicated,  easily  reduced  dislocation  in  a  healthy 
strong  adult: 

Begin  by  immobilizing  "the  shoulder,  but  take  care  that  after  three 
or  four  days  of  complete  rest  massage  and  passive  motion  shall  be 
begun.  The  joint  is  cautiously  put  through  all  its  motions,  the  deltoid, 
and  pect  ralis  major,  and  the  scapular  muscles  carefully  massaged; 
a  daily  seance  gradually  prolonged. 

In  the  interval  the  arm  is  bandaged,  but  gradually  the  dressing  is 
relaxed  and,  after  a  week,  movement  left  quite  free.  In  two  weeks  of 
such  treatment  the  function  may  be  entirely  restored. 

(B)  The  case  was  complicated  with  injury  to  the  soft  parts,  was 
with  difficulty  reduced,  and  only  after  a  number  of  attempts;  it  is 
likely   that    the   capsular   ligament    was  extremely  lacerated: 

Under  such  circumstances  not  only  passive  displacement,  but 
actual  dislocation  is  to  In-  feared.  Immobilize  the  joint  with  a  Mayor 
sling  or  Velpeau  bandage  and  let  it  so  remain  a  week.  But  this  will 
not   prevent   massage  over  the  shoulder  after  four  or  five  days.     Do 


266 


INJURIES    TO   JOINTS. 


not  prolong  the  fixation,  remembering  that  a  dislocation  accompanied 
by  great  violence  furnishes  the  condition  most  favorable  to  adhesions 
and  weakness,  and  against  these  evils  we  have  no  remedies  but 'mas- 
sage and  gymnastics,  which  must  be  early  begun  and  long  continued. 

DISLOCATION  OF  THE  LOWER  JAW. 

This  accident,  which  may  happen  at  most  unexpected  times,  when 

yawning  or  laughing,  for  instance, 
might  be  confused  with  certain 
fractures  of  the  inferior  maxilla. 
The  opened  mouth,  the  loss  of 
power  to  close  it,  are  characteristic 
(Fig.  191).  The  reduction  is 
usually  easy.  Both  sides  may  be 
reduced  simultaneously.  Wrap 
the  thumbs;  you  have  to  deal  with 
the  powerful  muscles  of  mastica- 
tion, which,  when  the  dislocation 
is  reduced,  are  likely  to  close  the 
jaws  with  much  force. 

The  thumbs,  passed  into  the 
mouth,  press  downward  and  back- 
ward on  the  molar  teeth;  at  the 
same  time,  the  fingers  hooked  under 
Fig.  191.— Dislocation  of  jaw.  {MouiUn.)  the  chin  pull  upward.  In  the  mus- 
cular, considerable  force  is  required. 

The  jaws  should  be  moved  only  slightly  for  several  days. 


DISLOCATION  OF  THE  ELBOW. 

Dislocation  of  the  elbow,  which  occurs  with  considerable  frequency, 
especially  in  children,  nearly  always  assumes  the  form  of  backward 
displacement. 

Diagnosis.- — The  elbow  is  increased  in  thickness  antero-posteriorly. 
The  flexure  of  the  joint  is  depressed.  Where  the  head  of  the  radius 
should  be  there  is  a  depression.     The  olecranon  is  abnormally  promi- 


REDUCTION    OF   Till      ELBOW-JOINT. 


267 


ni'iit.  Compare  the  relation  of  the  olecranon  to  the  inner  condylar 
lines  <m  the  two  sides.  Flexion  is  quite  painful  and  practically 
impossible. 


Pig.   iga. — Reduction  of   the  elbow-joint.     Traction  with  gradual  flexion  combined 
with  pressure  forward  on  the  olecranon. 

If  the  diagnosis  is  doubtful,  as  it  often  must  be  when  swelling  Is 
great,  one  thinks  of  supracondylar  fracture.  But  in  the  case  of  frac- 
ture, the  relation  of  the  olecranon  to  the  intercondylar  line  is  unaltered; 

the  humerus  is  shortened;  the  deformity  disappears  with  traction. 


268  INJURIES    TO   JOINTS. 

Reduction. — (A)  Standing  on  the  injured  side,  seize  the  arm  above 
the  elbow  with  both  hands,  and  as  an  assistant  makes  traction  on  the 
forearm,  steady  the  arm  and  press  with  both  thumbs  on  the  olecranon. 
The  traction  is  made  at  first  in  the  direction  of  the  long  axis,  but  as 
the  limb  yields,  the  forearm  is  rapidly  flexed — continuing  the  traction 
and  pressure.  By  this  means  reposition  is  usually  quite  easy. 
(Fig.  192.) 

(B)  Method  of  forced  extension: 

Traction  and  countertraction  as  before,  except  that  the  traction 
which  began  in  the  direction  of  the  long  axis  of  the  forearm  and  pro- 
duced flexion,  now  produces  hyper-extension.  In  the  meantime, 
press  on  the  olecranon  and  the  head  of  the  radius.  In  this  way,  one 
will  sometimes  succeed,  but  do  not  forget  this  method  is  available  only 
for  those  who  have  supple  joints. 

(C)  Method  of  Astley  Cooper: 

The  patient  is  seated  on  a  chair — you  place  yourself  on  the  side 
opposite  the  injured  elbow.  It  is  the  right,  for  example,  stand  upon 
the  left  side  and  place  a  foot  upon  the  chair.  Get  the  bend  of  the  el- 
bow over  the  knee.  Steadying  the  humerus  with  one  hand,  draw  on 
the  flexed  forearm  with  the  other,  at  the  same  time  flexing  the  elbow 
over  the  knee. 

Generally  speaking,  however,  if  the  first  method  fails,  it  is  better 
to  give  a  general  anesthetic,  with  which  the  chief  difficulties  disappear. 

Lateral  dislocations  are  usually  replaced  without  much  trouble  by 
pressure  combined  with  extension. 

After-treatment. — This  must  be  begun  even  earlier  than  for  the 
shoulder — massage  and  passive  motion — else  a  stiff  joint  is  very  likely 
to  follow. 

DISLOCATION  OF  THE  THUMB. 

This  accident,  apparently  simple,  presents  some  peculiarities,  which 
must  be  borne  in  mind. 

These  displacements  at  the  metacarpo-phalangeal  joint,  are  classi- 
fied as  incomplete,  complete,  and  complicated,  depending  upon  the 
relation  which  the  articular  surfaces  assume  and  upon  the  disposition 
of  the  sesamoid  bone  (Fig.  193).     Incomplete  dislocations  leave  the 


!■!  MM   iio\    OP    DISLOCATIONS    OF   THE    Till  MB. 


269 


articular  surfaces  in  slight  contact;  complete  dislocations  find  the  artic- 
ular surfaces  at  right  angles,  the  phalanx 
standing  upon  the  dorsum  of  the  meta 
carpal  (Fig.  194);  and,  if  in  addition  to  this, 
the  torn  anterior  ligament  and  sesamoid 
bone,  in  attempt  at  flexion,  arc  wedged  be- 
tween the  articular  surfaces,  the  dislocation  is 
said  to  be  com  plicated,  a  condition  difficult 
to  manage  (Fig.  195).  Since  this  condition  is 
produced  by  maladroit  attempts  at  reduction 
of  the  complete  dislocation,  it  is  especially 
desirable  to  understand  the  manoeuvres. 

Whether  the  dislocation  be  complete  or 
incomplete,  never  attempt  reduction  by 
flexion.  That  is  the  thing  to  be  avoided. 
Seize  the  thumb  and  slightly  bend  it  still 
further  backward,  at  the  same  time  pushing 
the   base   of  the    phalanx  obliquely  down-   Fig-  193.— Complete  dislocation 

1  l        J  of  thumb.     [Moullm.) 

ward   and  forward.      Directly   the    phalanx- 
will  be  felt  to  slide  over  the  head  of  the  metacarpal  into  its  place. 
Complicated   Dislocation. — (Lejars.)      Employ    general    anesthesia. 


1'ic.  [94,     Complete  dislocation 
of  thumb.     [Moullin.) 


Pig.  r 95. —Complicated  dislo- 
cation of  thumb.   (Moullin.) 


Only  the  most  carefully  regulated  manoeuvres  will  succeed.     Do  not 
attempt  the  reduction  unless  the  various  steps  are  clearly  in  mind. 


270 


INJURIES   TO   JOINTS. 


(1)  Make  traction  on  the  digit  in  the  direction  of  its  axis  until  it  is 
as  long  as  normal. 

(2)  Seizing  the  thumb  between  forefinger  and  thumb  in  such  manner 
that  your  thumb  presses  on  the  dorsal  surface  of  the  dislocated  joint, 
bend  it  backward  until  it  stands  perpendicular  to  the  metacarpal, 

or  even  further.  The  object  is  to  put 
the  thumb  in  the  position  of  uncompli- 
cated dislocation,  and  thus  disengage 
the  sesamoid  bone. 

(3)  Still  holding  it  at  that  angle, 
push  the  base  of  the  phalanx  forward. 

(4)  Having  pushed  the  phalanx  as 
far  forward  as  possible  in  this  man- 
ner, begin  suddenly  to  flex  it,  in  the 
meantime  keeping  the  last  phalanx 
extended  and  do  not  cease  to  push 
forward  while  flexing. 

If  failure  attends  two  or  three  at- 
tempts, do  not  persist;  proceed  to 
operate. 

Dislocations  of  the  fingers  should  be 
treated  in  the  same  manner — never 
begin  by  flexing. 

Reduce  by  first  bending  the  finger 
backward  and  then  pushing  the  base 
of  the  phalanx  forward.  In  every  case 
Fig.  196. -Backward  dislocation,  dorsum  the  purpose  is  to  reproduce  in  reduc- 

ilii ;  shortening,  inversion.      (Moullin.)      .  .  .    . .  ,  . 

tion  the  movements  01  dislocation. 


^^ 


DISLOCATION  OF  THE  HIP. 


These  accidents  are  always  serious,  and  yet  are  comparatively  rare. 
Of  the  different  forms  of  luxation  of  the  femoral  head,  the  backward 
on  the  dorsum  ilii  is  by  far  the  most  frequent  (Figs.  196,  197,  198). 

Diagnosis. — The  thigh  is  adducted,  rotated  inward,  and  practically 
immovable.     The  leg  is  apparently  shortened,  the  knee  slightly  flexed. 


REDUCTION    "l     nil     ll I r  JOIN  l  . 


[The  trochanter  rests  above  the  line  drawn  from  tin-  spine  of  the  ilium 
to  the  Ischial  tuberosity.  The  femoral  head  may  he  felt  under  the 
gluteal  mus<  les  on  the  dorsum  ilii. 


Fig.  197. 


I)isl<  cation  of  the  femur  upward  and  backward  in  a  child. 
The  arrow  points  to  the  acetabulum. 


Reduction. — General  anesthesia  is  often  necessary.  Lay  the  patient 
on  a  pallet  on  the  floor.  A  strong  assistant,  pressing  on  the  iliac 
spines,  immobilizes  the  pelvis. 

First  Movement:  Flexion  of  Thigh. — Grasp  the  thigh  above  the  knee 


272 


INJURIES    TO   JOINTS. 


with  one  hand  and  with  the  other,  the  leg,  and  gradually  flex  the  hip 
and  knee.     Flex  the  hip  to  a  right  angle. 

Second  Movement:   Traction  on  the  Flexed  Femur.— When  the  hip 
is  flexed  at  a  right  angle,  begin  traction,  maintaining  that  angle.     Do 


Fig.  198. — Backward  dislocation  of  the  head  of  femur.     Arrow  points  to  the  acetabulum. 


not  be  afraid  to  use  force.  This  is  the  most  important  manoeuvre. 
Properly  applied,  that  is  to  say,  with  powerful  traction  on  the  hip 
bent  at  a  right  angle,  the  effort  will  often  be  rewarded  by  a  sudden 
snap,  which  indicates  that  the  femoral  head  has  returned  to  its  socket 
(Fig.  199). 


Ki  DUI  I  [ON    "i     mi     nil'  JOINT. 


273 


Third  Movement:  External  Rotation  with  Abduction.-  Persisting  in 
the  traction,  the  resisting  mus<  les  arc  fell  to  yield.  Now  <  arry  out  the 
final  manoeuvre,  which  should  guide  the  head  over  the  rim  of  the  ace 


Pig.   199.  -Reduction  of  the  hip.     Flexion  <>f  the  knee.     Gradual  tK-xion  of 
the  hip  with  traction  on  thigh. 


kbulum  into  place.  Continue  traction  t<>  some  extent,  but  rotate  the 
pigh  outward  and  at  the  same  time  abduct.  All  the  other  methods 
proposed  are  hut  modifications  of  this  (Fig.  200). 


18 


274 


INJURIES    TO   JOINTS. 


ISCHIATIC  DISLOCATION. 

Diagnostic  points:  Adduction,  inward  rotation,  marked  flexion  of 
both  knee  and  hip  (Fig.  201). 


Fig.  200. — Reduction  of  hip.     Third  stage.     External  rotation. 
Hip  strongly  flexed. 


Reduction .— ^By  the  same  method  as  the  dorsum  ilii.     Do  not  begin 
the  final  movement  of  abduction  and  external  rotation  too  soon. 


Sill   IMIIIC    MSI  OCA  HON. 


275 


SUB-PUBIC  DISLOCATION. 

Diagnostic  points:  Compared  with  the  ischiatic  an  opposite  con- 
ation of  affairs  exists  abduction,  external  rotation  and  extension. 
1'he  great  trochanter  cannot  be  located  (Fig.  202). 


RlG.  201. — Dislocation  of  hip 
backward  into  the  sciatic  notch. 
Leg  shortened,  foot  inverted. 
{Motdlin.) 


Fig.  202. — Forward  dislocation: 
sub-pubic;  extension,  eversion. 
(Moullin.) 


Reduction. — Flexion  is  here  illusory,  and  equally  so,  blind  traction. 
Slightly  lifting  the  extended  limb,  abduct  it  as  far  as  possible;  while 
abducting  continue  to  lift.     The  head  rolls  down  toward  the  obturator 

foramen,   and   finally   the   thigh   stands   vertically.      Xow   adduct    and 
rotate  inward. 


276 


INJURIES    TO   JOINTS. 


OBTURATOR  DISLOCATION. 

Diagnostic  points:  The  hip  is  flexed,  abducted,  and  rotated  out- 
ward (Fig.  203). 

Reduction. — Flexion  of  hip,  traction  on  flexed  thigh,  adduction, 
inward  rotation. 

DISLOCATION  OF  THE  KNEE. 

This  accident  is  infrequent,  easy  of  diagnosis,  and  comparatively- 
easy  to  reduce. 

General  anesthesia  is  frequently  necessary.  Two  assistants  are 
needed,  one  for  traction  on  the  leg  and  one 
for  countertraction  on  the  thigh,  while  pres- 
sure is  applied  at  the  joint. 

One  must  be  concerned  here  with  the  con- 
dition of  the  blood  vessels.  Suppose  there 
is  no  pulse  at  the  ankle,  the  popliteal  space' 
is  evidently  filled  with  blood.  Under  these 
circumstances  apply  a  tourniquet,  and, 
under  rigid  antisepsis,  open  up  the  space  by 
a  longitudinal  incision,  turn  out  the  clotsJ 
ligate  the  torn  vessels.  Remove  the  tour-l 
niquet,  complete  the  hemostasis,  and  sew: 
up  the  wound.  The  limb  is  bandaged  in. 
cotton,  elevated,  and  kept  warm.  Time; 
alone  can  tell  whether  or  not  the  circulation 
will  be  restored  and  gangrene  averted. 

DISLOCATION  OF  THE  SEMILUNAR 
CARTILAGES. 


Fig.     203. — Downward  disloca 
tion.     Obturator.     (Moullin.) 


This  is  an  injury  likely  to  be  forgotten 
in  making  a  diagnosis  of  disabilities  of  the 
knee. 

The  internal  semilunar  cartilage  is  much  more  likely  to  be  inJ 
volved,  the  accident  usually  occurring  in  this  manner:  the  individual 
attempts  to  turn  suddenly  while  the  knee  is  flexed.  The  cartilage, 
either  as  a  whole  or,  more  often,  a  part,  projects  to  the  outside  or  in- 


I'lsr.OCATION   OF   THE   ANKLE-JOINT.  277 

side  of  the  joint  circumference.     There  is  a  sudden  painful  locking  of 
the  joint. 

The  patient  himself  is  often  able  to  relieve  the  condition  by  a  little 
manipulation  of  the  joint,  combined  with  lateral  pressure.  The 
injury  is  a  serious  one,  functionally,  and  demands  prolonged  rest,  in 
the  hope  that  union  may  occur.  An  elastic  silk  stocking  for  the  knee 
gives  support  and  tends  to  prevent  recurrence  of  the  trouble,  but 
violent  movements  are  almost  sure  to  bring  a  return.  If  asepsis  is 
assured,  the  joint  may  be  opened  and  the  cartilage  sutured  to  the 
tibia — an  operation  to  be  advised  by  the  general  practitioner  and  yet 
scarcely  ever  necessary  to  be  undertaken  by  him. 

DISLOCATION  OF     THE  PATELLA. 

The  difficulties  in  correcting  the  displacement  of  the  patella  are 
various,  depending  not  only  on  the  character  of  the  dislocation,  but 
also  on  the  condition  of  the  ligaments  and  muscles. 

In  general,  there  is  one  method  of  treatment,  viz.: 

Extend  the  leg  completely  and,  holding  it  in  extension,  flex  the 
thigh  to  a  right  angle.  By  this  means  the  quadriceps  extensor,  in 
whose  tendon  of  insertion  the  patella  is  lodged,  is  relaxed,  permitting 
the  bone  to  be  manipulated  into  place. 

DISLOCATION  OF  THE  ANKLE  AND  TARSUS. 

The  diagnosis  and  correction  of  these  injuries  are  more  especially 
matters  of  anatomy.  Whoever  has  clearly  in  mind  the  relations  of 
the  components  of  the  foot,  can  determine  the  character  of  the  disar- 
rangement with  the  minimum  difficulty. 

If  the  diagnosis  is  wrongly  made,  correct  reposition  is  lacking, 
and  in  consequence  there  persists  a  degree  of  deformity  and  loss  of 
function. 

One  must  begin  his  task  of  diagnosing  a  serious  injury  to  the  foot 
by  recalling  the  relations  of  the  malleoli  and  astragalus,  the  os  calcis, 
and  the  other  tarsal  bones,  to  each  other. 

Inspect  the  foot;  the  heel,  the  sole,  the  borders,  the  malleoli,  the 


278 


INJURIES    TO   JOINTS. 


tendo  achillis — and  compare  each  of  these,  point  for  point,  with  the 
sound  side.  Remember  that  the  line  of  the  tibial  crest,  prolonged, 
falls  on  the  second  toe. 

A  dislocation  of  the  ankle-joint  assumes  various  forms.  The  other 
bones  may  be  dislocated  from  the  astragalus,  which  retains  its  normal 
relation  to  the  malleoli.  There  may  be  solely  a  dislocation  of  the 
astragalus,  which  may  take  almost  any  position  imaginable.     Less 

often  one  finds  displacement  of  the  meta- 
tarsals and  phalanges. 

It  is  scarcely  possible  to  indicate  an  ex- 
act method  of  reducing  such  luxations. 
The  surgeon's  ingenuity  must  suggest  the 
proper  variations  of  traction  combined  with 
pressure.  A  type  may  be  found  in  backward 
dislocations  of  the  ankle  (Fig.  204). 

The  malleoli  are  carried  forward,  the 
heel  is  elongated,  the  foot  shortened. 
There  is  a  transverse  fold  in  front  of  the 
ankle,  ridged  vertically  by  the  stretched 
extensor  tendons. 

Reduction. — The  patient's  foot  projects 
over  the  end  of  the  couch,  an  assistant 
steadying  the  flexed  knee.  Grasp  the  heel  with  one  hand  and  the 
middle  of  the  foot  with  the  other  (Fig.  205).  Make  traction  at  first 
to  reflex  the  opposing  muscles  and  then  shove  the  foot  forward  and  at 
the  same  time  flex  it. 

After-treatment. — The  injured  joint,  carefully  padded,  must  be  fixed 
by  a  plaster  splint.  After  eight  to  ten  days,  passive  motion  and 
massage  must  be  begun. 


Fig.  204. — Backward  disloca- 
tion of  ankle.      {Moullin.) 


COMPOUND  DISLOCATIONS. 


These  are  accidents  always  to  be  dreaded,  and  yet  they  yield  ex- 
cellent results  under  antiseptic  methods. 

Before  you  is  a  joint  wide  open,  the  articular  surfaces  bare,  perhaps 
protruding,  and  immediately  you  think  of  resection  or  amputation, 


COMPOUND    DIS1  OCATIONS. 


279 


and  yet  you  will  do  neither.  Y<>u  will  proceed  to  do  a  most  careful 
disinfection  and  to  secure  a  complete  reposition  and  immobilization. 
The  one  chief  concern  is  disinfection. 

The  same  indications  for  treatment  are  present  as  in  compound 
fracture  into  joints  (sec  page  249)  and  depend  upon  the  degree  of 
injury  to  the  soft  parts  and  whether  the  infection  is  or  is  not  obvious. 

The  skin  about  the  wound  is  prepared  as  for  a  surgical  operation, 
the  wound  is  thoroughly  Hushed  out  with  sterile  water,  foreign  bodies 
are  removed,  and  replacement  is  effected.  The  next  step  will  vary, 
depending  upon  the  degree  of  confidence  in  having  completely  steril- 


^ 


Fig.   205. — Reduction  of  dislocated  ankle.     The  assistant   steadies  the 
flexed  knee.     {Heath.) 

ized  the  joint  cavity.  If  the  effort  has  been  exacting  in  that  regard, 
tightly  suture  the  deep  layers  over  the  joint,  close  the  superficial  layers 
with  interrupted  sutures  and  apply  drainage. 

If  the  articular  structures  were  impregnated  with  dirt,  one  will 
still  fear  suppuration  despite  the  greatest  care  in  cleansing,  and  will 
close  the  wound  less  firmly  and  provide  for  free  drainage.  Remov- 
ing as  many  bacteria  as  posible,  starving  those  that  remain  by  re- 
moving their  food  supply  devitalized  tissue  and  blood  serum — are 
the  principles  of  treatment:  cleansing  and  draining,  the  means; 
healing  without  inflammation  or  suppuration,  the  end. 

Dressing  and  After-care.  Having  provided  for  drainage,  cover  the 
wound  with  sterile  gauze,  envelop  the  limb  in  absorbent  cotton  and 
immobilize  the  joint  with  a  plaster  splint. 


280  INJURIES    TO   JOINTS. 

As  soon  as  the  soft  parts  are  healed  and  the  danger  of  infection  has 
passed,  begin  massage  of  the  muscles  and  slight  movement  of  the 
parts  daily. 

But  in  spite  of  careful  cleansing,  infection  may  develop.  On  the 
third  day,  perhaps,  a  chill  occurs,  the  fever  mounts  rapidly  and  there 
are  all  the  local  signs  of  inflammation  and  sepsis.  Do  not  temporize, 
but  immediately  open  the  wound,  douche  thoroughly  with  peroxide 
or  iodine  water  and  leave  the  wound  open.  Immobilize.  If  the 
temperature  does  not  fall  and  the  local  conditions  do  not  improve  in 
a  few  hours,  proceed  at  once  to  do  an  arthrotomy  (see  page  376). 

The  thorough  drainage  by  this  means  obtained  will  usually  control 
the  situation.  The  drainage  is  gradually  withdrawn  and  will  not  be 
necessary  after  about  the  tenth  day.  If,  even  then,  the  swelling  and 
fever  do  not  subside,  there  is  nothing  left  to  prevent  a  general  in- 
fection but  immediate  amputation,  and  even  that  may  be  too  late. 

The  shoulder- joint  rarely  suffers  a  compound  dislocation.  Such  an 
injury  is  especially  serious  for  the  reason  that  there  are  so  many  com- 
plications; the  shoulder  muscles  are  torn,  the  axillary  vessels  and  the 
nerves  of  the  brachial  plexus  lacerated. 

It  must  be  treated  on  the  general  principles  enumerated  and  the 
result  is  often  surprisingly  good.  If  traumatic  aneurysm  exists,  the 
pectoralis  muscles  must  be  divided,  the  space  exposed  and  the  vessels 
ligated. 

The  hip-joint  is  occasionally  the  site  of  a  compound  dislocation  and 
nearly  always  the  shock  is  fatal. 

Elbow. — This  is  a  comparatively  frequent  accident  and  is  treated 
on  the  general  principles  outlined.  If  the  injuries  are  severe,  a  partial 
excision  may  be  required  to  perfect  drainage  and  insure  a  better  joint. 
Amputation  will  be  indicated  only  in  old  age,  morbid  constitutional 
disability,  or  extreme  local  destruction. 

The  wrist  should  be  treated  conservatively.  A  loose  carpal  bone 
may  require  removal  or  partial  resection.  Amputation  will  be  re- 
quired if  healing  is  obviously  out  of  the  question. 

Compound  dislocations  of  the  knee-joint  are  very  rare.  If  con- 
servatism fails,  amputation  is  the  only  alternative. 

Ankle  and   Tarsus. — These  dislocations  are  frequent  and  require 


WOUNDS    m|      |  hi      KM   1     JOINT.  281 

much  attention.  Antiseptic  foot  baths  serve  an  excellent  purpose 
tlmuLih  the  primary  cleansing  must  he  especially  vigorous.  The 
larval  bones  may  need  t<>  be  sutured  to  be  retained  in  place.  Espe<  tal 
Bare  must  be  taken  not  to  interfere  with  the  circulation  (see  page  250, 
compound  fractures). 

CONTUSIONS  OF  THE  KNEE-JOINT. 

These  are  so  frequent  as  to  call  for  a  special  word.  The  aim  is  to 
avoid  an  acute  synovitis,  which  may  become  suppurative.  In  milder 
rest  in  bed  with  some  mild  liniment  and  light  massage  will 
be  sufficient,  and  the  pain  and  stiffness  will  rapidly  subside. 

In  the  severer  cases,  indicated  by  pain  and  swelling,  more  active 
measures  must  be  instituted. 

Wrap  the  joint  in  absorbent  cotton  and  apply  a  plaster  bandage  for 
two  or  three  days.  The  uniform  pressure  will  limit  the  effusion  and 
hasten  its  absorption.  After  that  you  may  begin  hot  sponging  and 
very  gentle  passive  motion  with  massage,  applied  at  first  only  to  the 
muscles  moving  the  joint,  and  afterward,  as  the  tenderness  subsides, 
to  the  joint  itself. 

PUNCTURE  AND  STAB  WOUNDS  OF  THE  KXKK-JOIXT. 

The  treatment  will  depend  largely  on  the  instrument  which  in- 
flicted the  wound  and  the  appearance  of  the  wound.  If  the  wound 
is  clean-cut,  and  the  instrument  presumably  non-septic,  content  your- 
self with  sterilizing  the  field  of  the  wound,  enveloping  the  knee  in  an 
antiseptic  compress  and  putting  the  joint  at  rest,  preferably  in  a  plaster 
splint.  You  will  anxiously  watch  the  temperature.  If  it  does  not 
rise  within  three  or  four  days,  one  may  cease  to  fear  infection,  and  such 
■welling  as  appears  is  not  significant. 

It  is  quite  different  when  the  temperature  begins  to  rise  and  the  local 
symptoms  gradually  increase,  <>r  if  the  wound  is  seen  after  some  days 
of  neglect  and  the  symptoms  of  infection  are  fully  developed. 

Under  these  circumstances,  there  must  be  no  delay.  Immediate 
operation  is  imperative;  it  is  indicated  to  do  an  arthrotomv.  disinfect 
and  drain  (see  page  376). 


252  INJURIES    TO   JOINTS. 

This  treatment,  early  and  properly  applied,  will  save  the  joint. 
As  infection  subsides,  the  drainage  is  gradually  withdrawn. 

There  are  cases,  however,  in  which,  unfortunately,  even  these 
strenuous  measures  fail.  In  spite  of  immediate  recognition  of  the 
urgency,  and  immediate  action,  laying  open  the  joint  with  the  utmost 
freedom,  followed  by  repeated  irrigations — in  spite  of  the  utmost 
endeavor,  the  symptoms  of  grave  general  infection  persist  and  it  is 
necessary  to  amputate.  This  may  save  the  patient's  life — more  often 
it  will  not. 

EXTENSIVE  INCISED  OR  LACERATED  WOUNDS  OF 
THE  KNEE-JOINT. 

In  these  cases,  it  is  never  sufficient  merely  to  cleanse  the  skin  and  seal 
the  wound  with  antiseptic  dressings.  The  wound  must  be  enlarged, 
thoroughly  cleansed,  and  the  joint  cavity  irrigated  with  sterile  water 
or  normal  salt  solution  and  wiped  dry  with  sterile  gauze. 

After  the  complete  disinfection,  the  wound  in  the  capsule  is  sutured 
and,  perhaps,  also  the  skin.  More  frequently,  however,  one  will 
feel  safer  to  leave  drainage  in  the  skin  wound.  The  joint  is  immobil- 
ized, and  if  everything  goes  well,  the  drainage-tube  is  removed  after 
forty-eight   hours. 

SPRAINS. 

In  general,  these  conditions  are  to  be  treated  by  firm  bandaging  for 
two  or  three  days,  to  limit  the  swelling  and  hasten  the  absorption  of 
the  effusion;  and  then  massage  and  slight  passive  motion  are  begun. 
It  is  better  to  give  the  joint  functional  rest  until  at  least  the  greater 
part  of  the  pain  has  subsided. 

The  ankle-joint  is  more  frequently  sprained  than  any  other,  partly 
on  account  of  its  construction  and  partly  on  account  of  its  function. 
The  weight  of  the  bodyWalls  on  the  insecurely  poised  foot  and  the 
ankle  gives  way  under  the  load.  The  ankle  usually  bends  outward 
and  the  external  lateral  ligaments  are  subjected  to  great  strain.  They 
are  undoubtedly  often  lacerated  or  the  capsular  ligament  may  be 
torn.     The  pain  in  the  severe  cases  is  immediate  and  intense;  the 


MASSAGE   01     \    SPRAINED  ANKLE.  283 

patient  may  faint.  If  the  joint  is  continued  in  use,  the  swelling  is 
aggravated,  hut  in  any  event  swelling  rapidly  ensues. 

Morphia  may  be  necessary  to  relieve  the  pain,  [fseen  al  once,  the 
ankle  is  immobilized  in  plaster  of  Paris  for  a  few  days,  or  bandaged 
tightly  with  a  flannel  or  ruhher  bandage,  or  strapped  with  adhesive 
plaster,  after  which  massage  and  passive  motion  are  employed.  The 
patient  should  walk  with  crutches  at  first.  The  joint  will  he  stronger 
than  if  it  was  used  before  the  pain  and  swelling  had  subsided,  although 
excellent  authorities  advise  walking  from  the  first. 

If  adhesive  strips  are  used,  in  order  to  avoid  circular  constriction, 
apply  them  in  this  manner:  cut  the  adhesive  strips  one-half  inch 
wide  and  in  two  lengths,  twelve  and  eighteen  inches. 

(1)  Begin  with  one  of  the  long  strips  in  front  of  the  big  toe,  carry 
the  strip  back  around  the  heel,  keeping  just  above  the  contour  of  the 
sole,  and  bring  the  strip  back  across  the  dorsum  of  the  foot  to  the 
starling-point.  Overlap  this  with  a  similar  strip.  Both  should  he 
tightly  drawn. 

(2)  Begin  with  one  of  the  shorter  pieces  above  the  ankle  and  carry 
it  under  the  heel  to  the  opposite  side. 

The  subsequent  strips  are  applied  alternately  in  this  fashion,  each 
overlapping  the"  one  preceding,  until  the  foot  is  practically  covered. 

The  whole  is  then  enclosed  in  an  ordinary  roller  bandage  and  the 
foot  kept  quiet.  After  two  or  three  days,  the  patient  may  begin  to 
move  around  a  little,  but  the  dressing  must  be  left  on  till  the  pain  ami 
swelling  have  subsided.  It  may  be  reinforced  by  additional  strips 
placed  over  the  loose  ones. 

The  manner  of  giving  massage  is  also  important.  In  the  ease  of  a 
tender  joint,  begin  by  gently  stroking  the  healthy  tissues  just  above 
the  joint  in  the  direction  of  the  blood  and  lymph  currents,  and  grad- 
ually approach  the  joint.  The  movements  are  gradually  made  more 
vigorous,  using  the  palmar  surface  of  the  hand.  After  a  few  minutes 
of  this  work,  the  joint  will  usually  permit  a  direct  manipulation  and 
finally  slighl  passive  movement  i--  begun. 


CHAPTER  XV. 
INJURY  AND  REPAIR  OF  TENDONS. 

There  are  three  kinds  of  injuries  to  tendons  which  it  is  practical  to 
consider  as  emergencies:  dislocated  tendons,  subcutaneous  rupture, 
and  divided  tendons. 

Dislocation  of  Tendons. — Dislocation  is  not  a  frequent  injury,  and 
yet  it  occurs  and  is  to  be  considered  as  a  possibility  in  making  a  diagno- 
sis of  disturbances  of  function  after  certain  joint  accidents.  Every 
sprain  should  be  examined  with  this  point  in  view. 

The  tendons  most  frequently  dislocated  are  those  of  the  peronei 
muscles,  especially  the  brevis.  Following  a  severe  wrench  of  the  ankle, 
it  is  torn  out  of  its  sheath  behind  the  external  malleolus  and  carried 
forward  onto  the  malleolus,  where  it  can  be  felt  and  moved. 

It  is  easily  replaced,  but  it  is  with  more  difficulty  retained.  The 
ankle  must  be  immobilized  at  a  right  angle  to  relax  the  calcaneo-fibular 
ligament,  and  the  tendon  retained  by  pressure  until  the  ruptured  ten- 
don sheath  or  lateral  ligament  is  healed,  which  will  require  about  four 
weeks.  It  will  sometimes  be  necessary  to  expose  the  tendon  and  re- 
pair the  ruptured  tissues. 

The  long  tendon  of  the  biceps  may  be  wrenched  from  its  groove  in 
the  humerus  and  the  loss  of  function  and  prominence  of  the  head  of 
the  humerus  may  suggest  dislocation  of  the  humerus.  As  a  rule, 
the  tendon  is  easily  replaced  by  a  little  manipulation,  but  the  useful- 
ness of  the  arm  will  be  impaired  for  a  long  time. 

The  other  tendons  of  ankle  and  wrist  occasionally  may  suffer  simi- 
larly, but  not  seriously. 

Subcutaneous  Rupture. — Subcutaneous  rupture  is  especially  likely 
to  occur  with  the  tendon  of  the  quadriceps  extensor  or  triceps  cubiti  or 
the  tendo  achillis.     A  sudden  violent  effort  is  the  usual  cause. 

The  pain,  the  loss  of  function,  the  gap  between  the  ends  of  the  rup- 
tured tendon,  and  the  history  of  sudden  muscular  contraction  point  to 
the  nature  of  the  injury. 

284 


R1  I'M   R]     (H     TENDONS. 


28S 


There  is  only  one  logical  treatment,  viz.:  l>y  an  incision  to  expose 

llu-  tendon  at  Once  and  by  some  of  the  methods  shortly  to  he  des<  rihed, 
reunite  the  parts  by  suture.  It  is  the  duty  of  the  doctor  to  insist  on 
nothing  less  (Fig.  206).  But  it  must  be  remembered  that  the  synovial 
sac  is  peculiarly  susceptible  to  infection  and  the  skin  over  the  patella 
difficult  to  sterilize. 


FlG.  2o<>.  -Repair  of  ruptured  tendon  of  quadriceps  extensor  femoris.  </,  tendon  ; 
c.  basting  stitches;  b,  sutures  uniting  posterior  edges;  a,  sutures  uniting  anterior 
edges  of  ruptured  tendon.      (Bryant.) 

If  this  procedure  is  not  followed,  it  remains  only  by  position,  rest,  and 
massage  to  favor  repair,  which,  at  the  hest,  will  be  uncertain  and  slow. 

The  position  must  be  such  as  to  relax  the  muscle,  the  limb  must  be 
immobilized,  and  after  the  first  few  days  massage  must  be  begun  and 
tarried  out  systematically. 

Gage,  of  Worcester,  Mass.,  treated  three  cases  of  rupture  of  quad- 


286 


INJURY  AND    REPAIR    OF   TENDONS. 


Fig.  207.  —  Incised  wound  of  back  of  wrist.     Divided  tendons  exposed.     {Veau.) 


Fig.  208. — "  Expression"  of  retracted  end  of  divided  tendon  by  forced  flexion 
and  compression  of  forearm.      {Veau.) 


OPERATION    "I     RUPTURED    I  I  \l'<>\. 


287 


riceps  extensor  in  1904.  The  history  of  one  of  the  cases  is  typical. 
A  man,  57  years  old,  slipped  and  fell  with  his  left  knee  doubled  under 
him.  He  could  not  lift  his  leg  from  the  ground.  Examination  an 
hour  later  showed  a  gap  6  cm.  wide  between  the  upper  border  oi  the 
patella  and  tin'  retracted  edge  of  the  quadriceps  tendon. 
Operation.     A  transverse  incision  was  made  across  the  front  of  the 


Pig.  209.     Exposure  of  tendons  by  cnlar^in^  wound  in  aponeurosis. 

Suturing  tendons.      I  I  'eau. ) 

knee  and  the  ruptured  tendon  exposed.  The  rupture  was  complete 
fcccepl  lor  a  few  fibers  on  the  outer  edge.  The  joint  was  exposed,  the 
clots  wiped  out.  The  edges  of  the  tendon  were  then  carefully  coapted 
with  interrupted  catgut  sutures.  The  leg  was  put  up  in  plaster  ol 
Paris  splint  for  seven  weeks.  After  that  it  was  massaged  daily  and  the 
splint  definitely  removed  at  the  end  of  twelve  weeks.  The  leu  became 
as  strong  and  flexible  as  before  die  ai  cident. 


205  INJURY  AND    REPAIR    OF   TENDONS. 

Divided  Tendons. — These  are  found  frequently,  especially  at  the 
wrist.  They  must  be  immediately  sutured  for  then  it  is  relatively  easy. 
Later  they  retract  or  acquire  adhesions  and  it  is  difficult  to  approxi- 
mate the  two  ends,  and  one  must  have  recourse  to  special  manoeuvres. 

Use  No.  i  or  No.  2  silk  or  chromicized  catgut.  A  small  curved 
needle  or  a  straight  sewing  needle  will  serve. 

Begin  by  carefully  disinfecting  the  wound  and  securing  complete 


ISP 


ccJ. 


7?P 


Fig.  210. — Cross  section  showing  relations  of  the  various  tendons  at  the  wrist- 
joint.  N.  R.,  radial  nerve;  L.F.P.,  long  flexor  of  the  thumb;  A.R.,  radial  artery; 
G.P.,  palmaris  longis;  N.M.,  median  nerve;  L.F.,  flexors  of  the  fingers;  A.C.,  ulnar 
artery ; \N.  C,  ulnar  nerve;  C.P.,  ext.  carp,  ulnar;  C.P.D.,  ext.  min.  dig.,  C.C.D.,  ext. 
com.  digitorum;  L.E.P.,  ext.  long,  pollicis;  R,  extensors  carp.  rad. ;  M.P. ;  supinator 
longus,  extensor  brev.  pollicis. 


hemostasis.  The  lower  ends  of  the  divided  tendons  will  usually  be 
found  near  the  lower  lip  of  the  wound  (Fig.  207).  Identify  each  and 
count  them  to  be  sure  none  have  been  overlooked.  At  the  same  time, 
see  if  a  nerve  has  been  divided.  Look  for  the  others  of  the  divided 
ends.  If  they  are  not  in  sight,  do  not  reach  blindly  for  them  with 
forceps,  but  attempt  to  bring  them  into  view  by  "expression,"  and  if 
this  fails,  boldly  enlarge  the  wound. 


SI    I  I    Kl      u|      ||  MioNS. 


289 


Expression. — Direct  the  assistant  to  grasp  the  member  above  the 
wound  with  both  hands  and  the  pressure  may  force 
the  tendons  into  view.  It"  the  extensor  tendons  are 
Involved,  employ  forced  flexion  with  the  pressure. 
(These  muscular  groups  are  more  or  less  unified  and 
the  undivided  tendons  put  on  the  stretch  help  to 
Drag  the  divided  tendons  into  view  (Fig.  208). 

If   this  method   does  not  succeed,  apply  a  roller 

bandage,  beginning  at  the  elbow  joint  in  the  case  of 

the  upper  extremity;  at  the   knee  in  the  case  of  the 

leg  or  foot,  and  carry  it  down  to  within  an  inch  of 

the  wound.      If  this,  too,  fails,  make  a  free  incision 

observing  this  point;  do  not  make  the  incision  directly 

over  the  tendon  for  it  may  later  acquire  adhesions 

to   the   scar  tissue,   interfering   with    its  free  move- 

nent  (Fig.  209).      Generally  with  a  little  patience  the 

tendon  is  found.     It  is  often  practical  after  incising 

the   skin   to   make  a  diagonal  incision  of  the  deep 

fascia  or  two  incisions  at  a  right  angle,  creating  a 

Bap  which  may  be  dissected  up  and  the  tendon  group 

well  exposed  (Fig.  210).  Fig.     211-One 

Suture  of  the  Tendon. — (A)  The  tendon  is  round,    tendon   of   medium 
.       .        .      .     ,  ...  0   .         ,  ,  size.     (Veau.) 

as  at  the  level  of  the  wrist-joint.     Seize  the  tendon 

with  a  dissecting  forceps,  being  careful  not  to  bruise  it.     Pass  a  suture 

through  the  whole  thickness 
one-quarter  inch  from  the  end 
(Fig.  211),  entering  the  super- 
ficial surface  and  emerging  on 
the  deep  surface  of  the  segment 
and  carrying  it  then  to  the  Other 
part;  entering  the  deep  surface 
and  emerging  on  the  superficial 
surface.  The  ends  of  the  di- 
\  ided  tendon  are  then  coapted 
and  the  suture  tied. 
The  suture  may  be  passed  laterally  instead  ^\  anteroposteriorly. 
19 


i  t»^j 


212. — Method  of  introducing  suture  for 
divided  tendon,      i  Mai 


2<JO 


INJURY  AND    REPAIR    OF   TENDONS. 


Fig.   213. — Suture  of  tendons  completed.     Repair  of  aponeurosis.     The  aponeurosis 
should  not  be  divided  directly  over  the  tendons  else  adhesions  may  occur.      (Veau.) 


Fig.  214. — Suture  of  a  flattened 
tendon.     (Veau.) 


Fig.  215. — Suture  of  a  lacer- 
ated tendon.      (Veau.) 


ANASTOMOSIS    OK     II  \DONS. 


29I 


If  the  ends  of  the  tendon  tome  together  well,  a  suture  may  be 
entered  one-half  inch  from  the  divided  end  and  passed  obliquely 
in  such  a  manner  that  it  emerges  from  the  cut  surface  and  then 
is  passed  into  the  cut  surface  of  the  opposite  end  and  emerges  sym- 
metrically with  (lie  original  point  of  entrance.  Marsee  advises 
passing  a  separate  suture  three  times  through  the  tendon,  tying  the 
corresponding  ends  (Fig.  212). 

Repair  the  wound  in  the  deep  fascia  by  a  continuous  suture,  being 
assured  once  more  that  no  nerve  is  divided  (Fig.  213). 

(B)  The  tendon  is  flattened.  In  this  case,  the  ends  must  overlap. 
Make  a  latero-lateral  anastomosis;  pass  the  suture  through  the  lower 
end  from  before  backward,  beginning  near  one  border.  y 
Next  pass  the  suture  through  the  upper  end  from  before 
backward  and  again  from  behind  forward.  Finally  pass 
the  suture  from  behind  forward  through  the  lower  end. 
When  the  suture  is  ready  to  tie,  the  lower  end  overlaps  the 
upper  (Fig.  214). 

(C)  The  tendon  is  shattered  or  lacerated.  In  this  case 
before  suturing  tie  a  firm  ligature  around  either  end,  which 
will  prevent  the  suture  from  pulling  out  (Fig.  215). 

(D)  The  tendon  is  voluminous.  In  this  case  it  is  better 
to  vary  the  method  a  little.  Pass  the  transverse  suture  as 
in  Fig.  2ii.  Before  tying  the  suture,  the  posterior  lips 
are  drawn  together  as  neatly  as  possible.  When  these 
sutures  are  all  tied,  finally  suture  the  anterior  lips  together. 
Over  all  suture  the  deep  fascia.  The  transverse  suture  fio.  2I6  — 
must  be  strong,  No.  3  silk  for  example,  though  the  others  elongating  °a 
may  be  finer.  '  tendon- 

(E)  The  ends  cannot  be  approximated.  This  will  not  happen  ex- 
cept in  the  neglected  cases.     Two  procedures  are  practical. 

(1)  The  space  may  be  bridged  by  sutures,  which  will  favor  reunion 
by  scar  tissue.  Begin  by  ligating  both  ends  (Fig.  215)  and  then  pass 
three  to  six  sutures  as  the  one  is  passed  in  the  figure. 

(2)  The  space  may  be  bridged  by  splitting  the  upper  tendon  in 
the  manner  indicated  in  Fig.  216.  Before  the  tendon  is  split,  it 
must  be  ligated  near  its  end.     In  the  case  of  the  tendo  achillis,  it  may 


2Q2 


INJURY  AND    REPAIR   OF   TENDONS. 


Fig.  217. — Suture  by  double  anastomosis 
when  the  two  ends  of  the  divided  tendon 
cannot  be  brought  in  contact.      (Veau.) 


Fig.  218. — The  upper  end  cannot  be 
found.  LSuture  to  adjoining  ^.tendon. 
(Veau.) 


Fig.  219. — The  long  extensor  of  the  thumb  divided,  the'upper  end  lost.""  The  ad- 
joining tendon  is  split  and  one  segment  sutured  to  long  extensor.  _  (Schwartz.) 


DRAINAG1      \l  II  R    TKN  PON-SUTURE 


293 


In-  lengthened  by  making  several  half  cross  sections  at  different  levels, 
|rs1  one  side  and  then  the  other. 

(3)   The  two  ends  may  be  sutured  to  a  neighboring  tendon  (Fig.  217). 

(F)  The  upper  portion  of  the  divided  tendon  cannot  be  found.  In  this 
case,  buttonhole  a  neighboring  tendon,  selecting  one  nearest  resem- 
bling in  Function  the  divided  one.  Into  the  slit  pass  the  end  of  the 
divided  tendon  and  fasten  with  one  or  two  sutures.  The  divided 
tendon  should  be  slightly  on  the  stretch  when  the  suturing  is  completed 
(Fig.  2.8). 

The  healthy  tendon  may  be  split  and  the  separated  portion  sutured 
to  the  divided  tendon  (Fig.  219). 


Fir..  220. — Plaster  splint  applied 
to  maintain  tlexion. 


Drainage. — Drainage  is  necessary  if  the  wound  was  accidental.  A 
small  drainage-tube  is  left  beneath  the  skin.  The  fascia  has  been 
completely  closed.     Apply  a  dry  antiseptic  and  absorbent  dressing. 

Immobilize  the  part  in  a  position,  flexion  or  extension,  to  relax  the 
tendons.  If  necessary,  apply  a  plaster  bandage  over  the  dressing. 
An  excellent  splint  is  made  by  taking  a  plaster  roller,  properly  soaked, 
and  folding  it  back  and  forth,  pressing  the  folds  carefully  together 
until  a  five-  to  eight-ply  splint  of  proper  width  and  Length  is  made. 
This  is  slightly  padded,  bandaged  in  place  and  held  at  the  necessary 
degree  of  flexion  till  set  (Fig.  220). 


CHAPTER  XVI. 
INJURY  AND  REPAIR  OF  NERVES. 

THE   REPAIR    OF    DIVIDED   NERVES. 

It  is  imperative  to  suture  a  divided  nerve  as  soon  as  the  condition 
is  recognized.  If  the  repair  is  made  at  once  it  is  more  easily  done  than 
the  suture  of  tendons,  for  the  ends  are  not  so  widely  separated;  but, 
on  the  other  hand,  it  is  more  delicate  work,  for  the  trunks  are  smaller. 
Do  not  handle  these  tissues  roughly  and,  above  all,  do  not  cleanse  the 
wound  with  strong  antiseptics,  such  as  bichloride  and  carbolic  acid. 

Remember  that  the  upper  part  of  the 
nerve  retains  its  sensitiveness  and  in  it  are 
the  essentials  of  repair.  The  lower  seg- 
ment degenerates  if  repair  is  neglected. 

It  is  usually  necessary  to  freshen  the 
ends,  but  one  must  be  very  sparing  of  the 
tissues,  removing  less  than  a  millimeter 
from  each  extremity,  using  fine  sharp 
scissors.  It  is  better  to  make  the  section 
oblique  (Fig.  221). 

Pass  a  silk  (No.  o)  suture  or  a  small 
catgut  with  a  round  needle  through  the 
whole  thickness,  as  in  the  case  of  a  round 
tendon  (Fig.  222),  draw  the  ends  together 
and  complete  the  repair  by  suturing  the 
lips,  passing  the  suture  through  the  nerve  sheath  only  (Fig.  223). 
Adjust  the  ends  exactly  and  always  where  possible  make  the  suture 
an  end-to-end  one. 

Repair  the  various  layers  of  fascia  with  great  care,  so  that  the  sutured 
nerve  may  be  isolated  and  removed  from  the  sources  of  infection. 
Employ  drainage  in  suturing  the  skin. 

For  the  rest,  the  treatment  is  the  same  as  for  any  other  wound. 

294 


Fig.  221. — Ob- 
lique section  of 
the   nerve  ends. 


Fig.  222. — 
Through  and 
through  suture 
of  nerve. 

(Veau.) 


CONTTSION     Wl>    COMPRESSION    OF    NERVES. 


295 


Secondary  Suture — It  may  be  Found  accessary  to  suture  a  nerve 
some  time  after  the  injury,  and  this  operation    will 
present  difficulties.     The  ends  may  be  separated  or 

they  may  be  imbedded  in  scar  tissue. 

A  knob  often  forms  on  the  proximal  stump.  In 
Such  a  case,  freshen  the  ends  and  pass  the  suture  in 
the  manner  pictured  (Fig.  224). 

If  the  two  ends  are  attached  by  a  fibrous  cord, 
split  the  sear  tissue  longitudinally  (Fig.  225),  and 
transform  the  longitudinal  fissure  into  a  transverse 
one  and  suture  (Fig.  226).  If  the  ends  cannot  be 
approximated  or  bridged  they  may  be  sutured  at 
different  levels  to  a  neighboring  nerve  in  the  manner 
described  under  Repair  of  Tendons. 

Warn  the  patient  that  it  may  be  a  long  time  before 
function  is  even  partially  restored.  In  the  mean- 
time, muscular  atrophy  must  be  prevented  by  per- 
sistent use  of  electricity,  and  massage. 


CONTUSION    AND    COMPRKSSION    OF    NERVES. 


Fig.  223. — Suture 
of  nerve  through  the 
sheath.      {Veau.) 


Al 


F 1 1 ; .   ...•(. 
of 


normal 


These  injuries  to  nerves  are  by  no 
means  infrequent,  following  blows,  gun- 
shot wounds,  machinery  accidents,  frac- 
tures, and  dislocations. 

The  symptoms  vary  from  slight  ting- 
ling to  complete  loss  of  function.  The 
loss  of  function  is  often  a  later  develop- 
ment, due  to  a  neuritis  following  the 
contusion,  and  is  accompanied  by 
neuralgia,  muscular  palsy  and  trophic 
alterations  corresponding  to  the  distri- 
bution of  the  nerve. 

Treatment. — The    immediate    indica 
tions  are  to  restore    the    parts    to    their 
condition    as   much   as   possible,   and    to   relieve   the   pain   by 


—Secondary  suture.   Method 
coaptation,     1 1  •an.) 


296 


INJURY  AND    REPAIR   OF   NERVES. 


hypodermic  injections  of  morphia  or  by  phenacetine  and  codeine.  The 
nerve  must  be  put  at  rest  by  immobilizing  the  limb.  Later,  alteratives, 
electricity,  and  massage  are  useful. 


INJURIES  TO  INDIVIDUAL  NERVES. 

Facial  Nerve. — The  facial  is  more  frequently  injured  than  any 
other  cranial  nerve:  in  fracture  of  the  base  of  the  skull;  in  the  mastoid 
operation  as  it  passes  through  the  temporal  bone;  by  shots  and  blows 

at  its  exit  from  the  styloid 
foramen.  Depending  upon 
the  distance  of  the  lesion  from 
the  central  origin  of  the  nerve, 
there  occur  paralysis  of  the 
muscles  of  expression,  dis- 
turbance of  salivary  secretion 
and  the  sense  of  taste,  and 
paralysis  of  the  palatal  mus- 
cles. Injury  to  the  facial 
nerve  is  often  accompanied 
by  injury  to  the  abducens 
and  auditory  nerves. 

To  Expose  the  Facial 
Nerve. — The  incision  begins 
behind  the  external  auditory 
meatus  and  extends  down- 
ward and  forward  to  the 
angle  of  the  lower  jaw. 

Divide  the  integument, 
superficial  fascia  and  the  first  layer  of  the  deep  fascia.  This  exposes 
the  parotid  gland,  the  sterno-cleido-mastoid  and  the  mastoid  process. 
The  posterior  auricular  nerves  and  the  vessels  are  to  be  avoided. 
Carefully  dissect  and  draw  forward  the  part  of  the  gland  exposed 
and  the  posterior  belly  of  the  digastric  appears,  just  above  which  the 
nerve  lies  upon  the  styloid  process. 

Optic  Nerve. — The  optic  nerves  are  injured  most  frequently  in  con- 


Fig.  225.  Fig.  226. 

The  two  ends  of  the  nerve  are  connected  by  a 
fibrous  cord  which  is  split  longitudinally  and  su- 
tured as  indicated.      (Veau.) 


EXAMINATION     I'OK     I1KAIN    TRAUMA.  297 

Lection  with  fracture  of  the  base  of  the  skull  involving  the  anterior 
fossa,  and  especially  when  the  fissure  involves  the  optic  foramen, 
for  there  the  nerve  is  firmly  attached  t<>  the  hone. 

As  a  consequence  of  such  injuries,  there  may  he  compression,  lacera- 
tion, or  extravasation  into  the  nerve  sheath.  As  a  result  of  these  in- 
juries, there  are  disturhanccs  of  vision  of  various  degrees.  In  obscure 
trauma  of  the  brain,  the  ophthalmoscopic  examination  of  the  fundus  of 
the  retina  should  never  be  neglected  as  a  means  of  diagnosis. 

Motor  (  huli  Nerve. — The  motor  oculi  nerve  may  be  injured  by 
wounds  penetrating  the  orbit  and  by  fractures  of  the  base.  Its  func- 
tion may  be  disturbed  by  pressure  following  the  rupture  of  the  middle 
meningeal  artery  and  often  the  only  indication  of  this  disturbance  is  a 
dilated  pupil  and  drooping  of  the  eyelid. 

Patheticus  and  Abduccns. — These  nerves  are  often  injured  along  with 
the  third. 

Fifth  Nerve. — The  fifth  nerve  is  rarely  injured  alone,  but  injury  of 
single  branches  may  occur. 

"The  usual  consequence  of  anesthesia  of  the  trigeminals  following 
cranial  injury  is  so-called  keratitis  neuroparalytica." 

Auditory  Nerve. — The  auditory  nerve  is  rarely  injured  without 
other  serious  lesions,  and  since  traumatic  disturbances  of  hearing  may 
be  due  to  injury  to  the  labyrinth  or  tympanum  also,  a  diagnosis  of  in- 
jury to  the  nerve  trunk  must  be  uncertain. 

The  pneumo gastric  may  be  divided  or  contused  by  bullet  or  stab 
wounds  in  the  neck.  The  injury  is  not  necessarily  fatal,  but  may  be 
followed  by  difficulty  in  respiration  and  deglutition  or  by  pneumonia. 
When  the  symptoms  point  to  injury  an  effort  should  be  made  to  repair 
it.  It  is  reached  by  the  same  operation  as  that  for  ligation  of  the  com- 
mon carotid. 

The  phrenic  when  divided  gives  rise  to  disturbances  of  the  functions 
of  the  diaphragm,  cough,  difficult  respiration. 

The  recurrent  laryngeal  when  divided  gives  rise  to  hoarseness  and 
aphonia.  If  injured,  an  attempt  should  be  made  at  repair.  Laryngeal 
spasm  may  require  a  tracheotomy. 

Median  Nerve. — The  median  nerve  is  likely  to  be  divided  by  Stab- 
or  gunshot  wounds  and  may  be  exposed  in  any  part  of  its  course. 


298  INJURY  AND    REPAIR    OF   NERVES. 

Injury  to  the  median  nerve  results  in  impaired  flexion  of  the  hand 
and  fingers  and  movements  of  the  thumb. 

To  Expose  the  Median  Nerve. — (A)  In  the  middle  third  of  the  arm 
(Fig.  227):  Place  the  patient  on  the  back  with  arms  abducted  to  a 
right  angle,  the  operator  standing  to  the  inner  side  of  the  arm. 

With  the  two  hands  define  the  biceps  muscle.  Along  the  inner 
border  of  the  muscle,  following  the  known  line  of  the  nerve  (from  the 
middle  of  the  axilla  to  the  middle  of  the  bend  of  the  elbow)  make  an 
incision  two  or  three  inches  long,  dividing  the  skin  and  connective 
tissue.     Divide  the  deep  fascia  over  the  biceps  and  open  the  sheath 


Fig.  227. — Exposure  of  the  median  nerve^in  the  middle'third  of  the  arm.      B.  Biceps. 
M.  N.  Median  nerve.      B.  A.  Brachial  artery.      {Schwartz.) 

of  the  muscle.  Isolate  the  border  of  the  muscle  and  with  the  retractor 
draw  it  gently  aside.  Do  not  use  force  or  the  nerve  also  will  be  dis- 
placed or  the  musculo-cutaneous  may  be  exposed  instead  of  the  median. 
Now  incise  the  deep  layer  of  the  muscle  sheath  exactly  in  the  line 
that  was  occupied  by  the  border  of  the  muscle  and  the  nerve  is  exposed 
lying  a  little  to  the  inside  of  the  vessels. 

(B)  At  bend  of  elbow  (see  Brachial  Artery). 

(C)  In  the  upper  third  of  the  forearm  (Fig.  228) :  The  incision  begins 
a  little  below  the  bend  of  the  elbow,  is  two  or  three  inches  in  length, 
and  follows  the  line  of  the  nerve,  which  lies  in  the  middle  line  from 


l\  11  kv    rO    nil     i  I  \  \K    NERVE. 


299 


the  elbow  to  the  wrist.  Divide  the  skin  and  ligate  the  two  superfii  ial 
veins.     Under  the  deep  fascia  define  the  external  border  of  the  pro- 

nai  r  radii  tries  and  over  this  border  incise  the  aponeurosis  and  retrai  t 
the  muscle. 

The  nerve  is  immediately  exposed,  together  with  the  ulnar  artery, 
which  crosses  beneath  it,  running  obliquely  toward  the  inner  border 
of  the  forearm. 

(D)  At  the  wrist  (Fig.  229).  Make  an  incision  two  inches  in  length 
in  the  middle  line,  the  middle  of  the  incision  corresponding  to  the 


Fig.  228. — Exposure  of  the'median  nerve  just  below  the  elbow.  The  pronator 
radii  teres  (p.  R.  t.)  drawn  inward  exposing  the  median  nerve  (m.  n.),  the  ulnar 
artery  (u.  art.)  being  at  outer  side.     (Schwartz.) 


:rease  of  the  wrist.  Divide  first  the  skin  and  the  fascia  and  then,  very 
arefully,  the  anterior  annular  ligament,  guarding  the  synovial  sheath 
)f  the  flexor  tendons.  Retract  the  lips  of  the  wound,  and  the  nerve  is 
iposed,  easily  distinguishable  from  the  adjacent  tendons  by  its 
ibrillated  appearance. 

The  Ulnar  Nerve  (Fig.  230). — The  ulnar  nerve  may  be  divided  any- 
vherc  along  its  course,  but  is  more  likely  to  be  contused  in  the  ulnar 
groove.  There  also  it  may  be  dislocated  by  forcible  flexion  of  the 
orearm.  The  loss  of  function  of  this  nerve  results  in  inability  to  extend 
lie  distal  phalanges,  to  adducl  the  fingers  and  to  ilex  the  little  finger. 


3°° 


INJURY  AND    REPAIR   OF   NERVES. 

claw  hand"  appears  as  a  result  of  atrophy  of  the 


Eventually  the 
muscles. 

To  Expose  the  Ulnar  Nerve. — (A)  In  the  arm:  Make  an  incision 
two  or  three  inches  in  length  along  the  line  of  the  nerve,  which  extends 
from  the  middle  of  the  axilla  to  the  internal  condyle.  Divide  the 
skin  and  superficial  and  deep  fascia.  The  brachial  artery  is  about 
a  finger's  breadth  to  the  outside  of  the  line  of  incision.     Draw  the 


Med.N. 


Fig.  229. 


—Exposure  of  the  median  nerve  at 
the  wrist.      (Schwartz.) 


Fig.  230. — Exposure  of  the  ulnar  nerve  in 
the  upper  third  of  the  arm.  M.  N.  Median 
nerve.  B.  A.  Brachial  artery.  U.N.  Ulnar 
nerve.     Tr.  Triceps  muscle.      (Schwartz.) 


basilic  vein  to  one  side.  Carefully  divide  the  subjacent  tissue  be- 
neath which  is  the  ulnar  and  median  nerves  and  the  brachial  artery; 
the  ulnar  nerve  is  to  the  inside  and  in  contact  with  the  long  head  of 
the  triceps. 

(B)  At  the  elbow  (Fig.  231):  Place  the  patient  on  the  back;  abduct 
the  arm;  flex  the  forearm  at  a  right  angle;  stand  to  the  inner  side 
of  the  arm  and  locate  the  inner  condyle,  the  olecranon  and  the  in- 
tervening gutter.     Along  the  line  of  the  gutter  incise  the  skin  and  the 


INJURY    TO    MUSC1  LO  SPIRAL    NERVE 


3QI 


ksi  ias  for  two  or  three  inches,  and  the  nerve  will  be  exposed,  accom- 
panied by  the  posterior  ulnar  recurrenl  artery. 

(C)  In    the   lower  third  of  the  forearm   (Fig.   232):     Following  the 
linr  of  the  nerve,  from  the  internal  condyle  to  the  radial  side  of  the 

pisiform,  make  an  incision  two  inches  long  to  the  outside  of  the  flexor 
carpi  ulnaris,  dividing  the  skin  and  superficial  fascia.  Retract  inward 
the  tendon  of  this  flexor.  Carefully  incise  the  deep  fascia  and  the  nerve 
is  exposed  lying  to  the  ulnar  side  of  the  ulnar  artery. 


PlG.  231. — Exposure  of  the  ulnar  nerve  at  elbow.  I.  C.  Internal  condyle. 
E.  C.  U.  Extensor  carpi  ulnaris.  U.  N.  Ulnar  nerve.  Olec.  Olecranon  process. 
Trie.  Triceps.     (Schwartz.) 


Musctdo-spiral. — The  musculo-spiral,  more  than  any  other  nerve 
of  the  arm,  is  subject  to  injury  from  stab,  contused,  or  gunshot  wounds 
or  to  fracture  of  the  humerus.  Very  characteristic,  too,  are  the 
Symptoms  resulting  from  its  loss  of  function.  The  wrist  and  fingers 
cannot  be  extended  and  assume  the  attitude  well  known  as  the  "drop 
wrist."  In  every  fracture  of  the  humerus,  the  stability  of  this  nerve 
should  be  tested.  The  nerve  may  be  explored  in  any  part  of  its 
course,  but  is  most  easily  reached  at  the  outer  side  of  the  arm  just  above 

the  elbow. 


302  INJURY  AND    REPAIR    OF    NERVES. 

To  Expose  the  Musculo-spiral. — In  the  lower  third  of  the  arm  (Fig, 
233) :  The  arm  is  abducted,  the  forearm  extended  and  the  hand 
supinated.  Stand  to  the  outside  of  the  limb.  In  the  line  of  the  nerve, 
a  line  drawn  along  the  middle  of  the  external  surface,  beginning 
half-way  between  the  shoulder  and  elbow  and  extending  to  a  poinl 
one-half  inch  from  the  center  of  the  bend  of  the  elbow,  make  ar 
incision  two  or  three  inches  in  length  through  the  skin  and  superficia 
fascia.  Retract  the  cephalic  vein.  Divide  the  deep  fascia  along  the 
border  of  the  supinator  longus  and  expose  the  muscle  fully.     Retract 


pIG    232  Exposure  of  the  ulnar  nerve  at  the  wrist.     U.  A.  Ulnar  artery. 

U.  N.  Ulnar  nerve.     {Schwartz.) 

it  to  the  outside.  At  the  bottom  of  the  wound  is  the  nerve  lying  upoi 
the  brachialis  anticus. 

Circumflex. — In  addition  to  such  injuries  as  may  be  due  to  stab  oi 
gunshot  wounds,  the  circumflex  is  liable  to  be  lacerated  in  violen 
wrenching  or  in  dislocation  of  the  shoulder-joint. 

The  loss  of  power  to  abduct  the  arm  through  paralysis  of  the  deltoic 
is  the  immediate  result.  The  nerve  may  be  exposed  as  it  winds  arounc 
the  humerus  just  below  its  head. 

Operation. — The  course  of  the  nerve  is  in  a  line  drawn  from  the  innei 
end  of  the  scapular  spine  to  the  point  of  insertion  of  the  deltoid. 

Place  the  patient  on  the  sound  side,  exposing  the  shoulder  well  b) 
rotating  the  arm  inward  a  little  and  placing  it  in  front  of  the  trunk 


INJURY   TO   Till.   ANTERIOR    CRURAL    NERVE.  303 

Along  the  line  indicated  make  an  incision  three  or  four  inches  long, 
corresponding  at  its  outer  end  to  the  acromion  process,  but  an  inch  or 
two  from  it.  This  incision  divides  the  skin  and  superficial  and  deep 
fascia  and  exposes  the  posterior  border  of  the  deltoid.  Bring  into 
view  and  draw  upward  this  border  of  the  deltoid. 

Next  locate  the  quadrilateral  space,  bounded  above  by  the  teres 
minor,  below  by  teres  major,  posteriorly  by  the  long  head  of  the  triceps, 


Sup.  Long. 
Mus.  Sp. 
Br.  Ant. 


pu;  233 — Exposure  of  the  musculo-spiral  in  its  lower  third.  The  supinator 
longus  is  exposed  and  the  nerve  found  to  its  inner  side  lying  upon  the  brachialis 
anticus.      (Schwartz.) 

and  anteriorly  by  the  shaft  of  the  humerus.  By  locating  the  tendons 
of  these  muscles  define  this  space  in  which  lie  the  nerve  and  the 
posterior  circumflex  artery  (Fig.  234). 

The  musculo-cutaneous  is  exposed  in  the  same  manner  as  the  median 
in  the  upper  third  of  the  arm  (Fig.  235). 

Anterior  Crural. — The  division  of  the  anterior  crural  nerve  means, 
among  other  things,  loss  of  extension  of  the  leg. 

To  outline  it  locate  the  spine  of  the  pubes  and  the  anterior  superior 
iliac  spine,  which  points  are  connected  by  Poupart's  ligament;  under 


3°4 


INJURY  AND    REPAIR   OP    NERVES. 


this  ligament  a  finger's  breadth  outside  of  its  middle  point  the  nerve 
passes  (Fig.  236). 

To  Expose  the  Anterior  Crural. — Make  an  incision  from  this  point 
downward  in  the  axis  of  the  thigh,  about  three  inches  in  length,  divid- 
ing the  skin. 


Fig.  234. — Exposure  of  the  circumflex  nerve.  D.  Deltoid.  T.  M.  Teres  minor. 
Tr.  Triceps.  T.  Maj.  Teres  major.  C.  A.  Circumflex  artery.  C.  N.  Circumflex 
nerve.      {Schwartz.) 


At  the  upper  end  of  the  wound  expose  the  lower  border  of  Poupart's 
ligament.  Immediately  below  this  line,  open  up  the  sheath  of  the 
psoas  magnus,  pass  a  grooved  director  under  the  sheath,  and  divide  it 
to  the  same  extent  as  the  skin  incision.  Separating  the  lips  of  the  sheath 
wound,  the  nerve  is  seen  lying  on  the  fibers  of  the  muscle  and  is  to  be 
distinguished  by  its  whiteness  and  its  subdivisions. 


AN  I  I  RIOB    CRT  RA1    M  RVE. 


305 


Fig.  235. — Exposure  of  the  musculo-cutaneous  nerve  in  the  middle  third  of  arm. 
The  biceps  (B)  drawn  outward  exposes  the  nerve  (M.  Cut.  N.)  lying  to  the  outside 
of  the  median  nerve  (Med.  N.)  and  the  brachial  artery,  Br.  Art.     (Schwartz.) 


' 


Fig.  236. — Anterior  crural  and  external  cutaneous  nerves.      (Labcy.) 


3°6 


INJURY  AND    REPAIR    OF   NERVES. 


The  Obturator. — If  the  obturator  is  divided,  there  follows  loss  of  ab- 
duction of  the  thigh. 

To  Expose  the  Obturator. — Abduct  the  thigh  until  the  border  of  the 
ductor  longus  can  be  clearly  defined,  and  along  this  line  make  an  in- 
cision four  or  five  inches  long,  beginning  an  inch  below  the  fold  of  the 
groin,  a  little  to  the  outside  of  the  scrotal  base.  Divide  the  skin  and 
superficial  fascia,  retracting  to  the  outer  side  the  internal  saphenous 


Fig. 


-Exposure  of  the  obturator  nerve;  separating  the  adductor  longus  from 
the  pectineus.      (Labey.) 


vein,  but  ligating  its  cross  branches. (Fig.  237).     Divide  the  deep  fascia 
in  the  same  line. 

Separate  the  adductor  longus  from  the  pectineus  by  blunt  dissection. 
A  fairly  well-defined  gutter  indicates  the  line  of  separation.  Retract 
the  two  muscles  and  at  the  bottom  of  the  upper  part  of  the  wound  you 
will  see  the  obturator  nerve,  consisting  of  a  couple  of  flattened  cords. 
Now  extend  the  thigh  to  relax  the  abductors  and  separate  more  widely 
the  two  muscles  mentioned  and  the  nerve  may  be  completely  exposed, 


EXPOSURE    Oh'    Till.    SCIATIC    M  R\  I  . 


307 


one  branch  lying  upon  the  adductor  brevis  and  the  other  passing  under 
it  (Fig.  238). 

Ilio-inguinal  and  Genito-crural. — These  nerves  are  frequently 
wounded  in  hernia  operations,  and  may  give  rise  to  an  obstinate  neu- 
ralgia of  the  testicle  requiring  removal  of  this  organ.  In  such  a  case 
an  effort  should  first  be  made  to  repair  the  nerve  or  resect  it. 

The  Sciatic  Nerve. — The  sciatic  nerve  may  be  injured  in  many  ways 
and  from  the  functional  point  of  view,  these  injuries  are  always  serious. 


Fig.  238. — Obturator  exposed.     (Labey.) 


It  may  mean  loss  of  extension  of  the  thigh  and  complete  paralysis  of 
the  leg. 

It  may  be  exposed  at  any  part  of  its  course  down  the  back  of  the 
thigh. 

Exposure  in  the  Middle  of  the  Thigh. — Place  the  patient  face  down- 
ward or  on  the  sound  side.  Along  the  line  of  the  nerve  (a  straight  line 
extending  from  a  point  midway  between  the  ischial  tuberosity  and 
the  great  trochanter  to  the  middle  of  the  popliteal  space),  make  an  in- 
cision three  or  four  inches  long,  dividing  the  tissues  down  to  the  deep 


3o8 


INJURY  AND    REPAIR   OF    NERVES. 


fascia.  Determine  the  interspace  between  the  biceps  and  the  internal 
hamstring,  and  over  it  divide  the  deep  fascia  and  separate  by  blunt 
dissection  the  muscles  of  the  space. 

Flex  the  leg  so  as  to  relax  them.  They  are  then  to  be  retracted 
widely  and  in  the  fatty  tissues  of  the  interval  the  nerve  is  usually  easily 
found. 

The  External  Popliteal,  or  Peroneal.- — This  nerve,  like  others,  is 
liable  to  injury  in.  fractures  and  wounds.  When  it  is  divided,  "foot 
drop"  occurs.  The  patient  cannot  walk  without  stubbing  the  great 
toe  and  to  prevent  this,  the  whole  leg  is  raised  (steppage  gait).     This 

nerve  bears  an  important  relation 
to  the  knee-joint  and  to  the  tendon 
of  the  biceps. 

To  expose  the  peroneal  behind 
the  head  of  the  fibula  place  the 
patient  face  downward  or  on  the 
sound  side.  The  line  of  the  nerve 
corresponds  to  the  tendon  of  the 
biceps,  which  may  be  palpated 
along  the  external  border  of  the 
popliteal  space,  or  the  course  of 
the  nerve  may  be  indicated  by  a 
line  drawn  from  the  tuberosity  of 
the  ischium  to  the  head  of  the 
fibula.  In  this  line,  beginning  at  the  neck  of  the  fibula,  make  an  in- 
cision upward  three  inches  long,  dividing  the  structures  down  to  the 
deep  fascia.  Carefully  divide  the  deep  fascia  over  the  tendon  of  the 
biceps  and  at  once  there  comes  into  view  the  external  popliteal,  lying 
to  the  inner  side  of  the  tendon  resting  upon  the  external  condyle  of 
the  femur  above,  and  lower  down  winding  about  the  neck  of  the  fibula 
and  disappearing  in  the  peroneus  longus. 

To  Expose  the  Musculo-cutaneous .- — Place  the  patient  upon  his  back, 
the  knee  flexed  and  rotated  inward,  and  retained  by  a  cushion  placed 
under  the  thigh ;  in  this  manner  exposing  the  external  aspect  of  the  leg. 
The  line  of  the  nerve  is  drawn  from  the  anterior  border  of  the  pero- 
neal head  to  the  anterior  border  of  the  external  malleolus.     Along  this 


Fig.  239. — Musculo-cutaneous  nerve  lying 
upon  the  peroneus  brevis.     (Labey.) 


EXP0SUR1     "I     I  in      INT]  RIOH    TIBIAL    M  in  I  . 


3°y 


line,  in  the  middle  <>i"  the  leg,  make  an  incision  three  or  four  in<  hes  in 

length  dividing  the  structures  to  the  deep  fascia. 

[ncise  the  aponeurosis  of  the  peronei  muscles,  isolate  the  anterior 

honler  of  the  peroneus  longus  and  draw  it  backward.     The  muscle 
may  be  previously  relaxed  by  rotating  the  foot 
outward.     The  nerve  will  be  seen  resting  upon 
the  peroneus  brevis  (Fig.  239). 

The  Anterior  Tibial  Nerve. — The  anterior 
tibial  nerve  is  the  continuation  of  the  external 
popliteal  nerve.  The  movements  of  flexion  of 
the  foot  and  extension  of  the  toes  depend  upon 
this  nerve. 

To  Expose  the  Anterior  Tibial  Nerve. — 
(A)  In  the  tipper  third:  Put  the  patient  in  the 
same  position  as  for  the  musculo-cutaneous. 

The  line  of  the  nerve  is  drawn  from  the  front 
of  the  peroneal  head  to  the  middle  of  the  ankle- 
joint  (Fig.  240). 

In  the  line  of  the  nerve  make  an  incision 
beginning  three  fingers'  breadth  below  the 
articular  line  of  the  knee.  Divide  to  the  deep 
fascia;  next  divide  that  and  then  patiently 
Beari  b  Eor  the  intermuscular  septum  separat- 
ing the  wide  tibialis  anticus  from  the  narrow 
common  extensor.  It  will  aid  greatly  in  the 
search  to  seize  with  a  forceps  each  of  the  lips 
of  the  wound  of  the  sheath  and  retract.  This 
will  help  to  develop  the  line  of  cleavage. 

_.  ,  .  .  .,  .    ,.  .  1-    1     1  Fig.   240. — Lines  repre- 

Kemember  that  the  tibialis  anticus  slightly     renting  the  course  (c)  of 

the      musculocutaneous; 
Overlaps     the     common    extensor,    SO    that    the      iab)  Anterior  tibial  nerves. 

intermuscular  space  slopes  inward  and  back- 
ward.      Retracting    the    muscles,   the   nerve   will   appear  as   a   small 
rounded  white  cord  lying  in  front  of  the  vessels. 
(B)    ///  the  lower  third  (see  Anterior  Tibial  Artery). 

Posterior  Tibial  Nerve. — The  posterior  tibial  nerve  supplies  the 
movements  of  the  extension  of  the  foot  and  flexion  oi  the  toes  and  mav 


310  INJURY  AND    REPAIR   OF   NERVES. 

be  wounded  in  any  part  of  its  course,  although  in  the  region  of  the  calf 
it  is  deeply  situated.  Behind  the  internal  malleolus  it  is  superficial 
and  easily  exposed. 

(A)  To  Expose  Upper  Third. — To  expose  the  posterior  tibial  in  the 
region  of  the  calf  is  difficult  (Fig.  241). 

Position. — Place  the  patient  on  his  back  with  the  thigh  in  abduction 
and  external  rotation,  the  knee  flexed,  and  the  foot  lying  upon  its  ex- 
ternal border  and  held  in  this  position  by  an  assistant.  Standing  to  the 
outside  of  the  limb  the  operator  with  this  arrangement  can  see  quite 
well  the  internal  surface  of  the  leg. 


Fig.  241. — Exposure  of  the  post,  tibial  nerve.     Gastrocnemius  retracted; 
soleus  exposed.     (Labey.) 


Locate  first  the  sharp  internal  border  of  the  tibia,  and  a  finger's 
breadth  behind  it  make  an  incision  four  inches  long,  beginning  at  the 
level  of  the  tuberosity.  Divide  the  tissues  down  to  the  deep  fascia, 
avoiding  the  internal  saphenous  vein,  which  lies  close  to  the  tibial 
border. 

Slightly  retract  the  posterior  lip,  which  will  include  the  gastrocne- 
mius, and  in  this  manner  the  soleus  is  exposed.  Division  of  the  soleus 
is  the  next  step  which  must  be  carefully  carried  out.  Divide  it  longi- 
tudinally, but  further  away  from  the  tibia  than  the  original  incision. 


I  XP0S1  K'l     01     I  ill      Wil  RIOB    M.R\  I 


$11 


Cutting  in  this  manner  through  the  fibers  of  the  sulcus,  the  yellow 
aponeurosis  covering  the  nerve  and  vessels  is  exposed  (Fig.  212). 
It  is  important  to  expose  this  landmark  well.     Make  an  opening  in  it 


Fie.   242. — Fibers  of  the  soleus  divided  and  retracted,  exposing  deeply 
situated  the  posterior  tibial  nerve  and  artery.     (Labey.) 


an  inch  and  a  half  from  the  internal  border  of  the  tibia,  and  beneath 
the  opening  is  the  nerve,  lying  to  the  outer  side  of  the  artery. 

(B)   Behind  the  ankle  (see  Ligation  of  Posterior  Tibial  Artery). 


CHAPTER  XVII. 
ABSCESS. 

An  abscess  is  a  circumscribed  collection  of  the  liquefied  products  of 
infective  inflammation. 

There  are  two  kinds  of  abscesses,  differing  in  their  etiology,  clinical 
history,  prognosis,  and  treatment.  All  these  differences  arise  primarily 
in  the  nature  of  the  infective  agent.  The  acute  abscess  is  due  most 
generally  to  the  activity  of  certain  of  the  cocci.  The  chronic  (or  cold) 
abscess  is  nearly  always  due  to  the  Bacillus  tuberculosis.  The  chronic 
abscess  may  become  infected  secondarily  with  the  germs  of  acute  in- 
flammation, in  which  instance  it  takes  on  the  character  of  the  acute 
abscess. 

The  content  of  the  acute  abscess  is  pus;  that  of  the  chronic  abscess, 
though  resembling  pus,  may  be  merely  the  liquefied  caseated  matter 
of  the  tubercle  without  any  pus  cells  whatever.  An  acute  abscess  pre- 
sents all  the  cardinal  symptoms  of  inflammation:  constitutional  dis- 
turbance, pain,  heat,  redness,  swelling,  all  in  greater  or  less  degree, 
depending  on  the  locality.  A  chronic  abscess  may  present  none  of 
these  symptoms  except  swelling,  and  where  swelling  is  not  perceptible 
the  abscess  is  frequently  unsuspected.  An  acute  abscess  is  of  very 
rapid  development — the  chronic  of  quite  slow  growth,  as  a  rule.  An 
acute  abscess  demands  immediate  evacuation  by  free  incision  and 
drainage.  The  chronic  abscess  very  often  permits  only  of  aseptic 
puncture,  followed  by  the  injection  of  detergent  remedies,  and  aseptic 
occlusion. 

Each  occurs  by  choice  in  certain  locations.  The  incision,  the 
special  dangers  and  details  of  treatment  depend  on  the  anatomy  of 
the  parts,  so  that  the  more  common  abscesses  require  individual 
consideration,  and  in  that  connection  the  general  principles  that  under- 
lie the  subject  may  be  elaborated. 

The  prevention  of  pus  formation  should  be  attempted  in  all  acute 

312 


TRIM  mini    <u    ACT   l  I     ABSCESS.  313 

infectious  inflammations  by  means  of  the  timely  application,  in  favor- 
able localities,  of  hot  antiseptic  poultices  or  prolonged  immersion  in 
hot  antiseptic  solutions.  Even  though  the  treatment  fails  to  pre 
vent  suppuration,  it  will  at  least  limit  it.  Such  an  antiseptic  poultice 
may  be  made  by  applying  absorbent  cotton  soaked  in  hot  boric  acid 
solution  and  covering  it  with  oiled  silk  or  gutta-percha.  In  this  manner 
heat  and  moisture  are  retained. 

The  old  rlaxseed-meal  poultice  is  more  often  than  not  the  breeder 
ot  uerms  and  therefore  distinctly  non-surgical — a  domestic  make- 
shift. Some  of  the  "antiphlogistic"  glycerinated  and  sterile  clay 
bastes  often  render  an  excellent  service. 

Treatment. — The  evacuation  of  an  abscess  is  by  many  regarded  as 
a  small  procedure  in  minor  surgery.  It  may  be  nothing  more,  and  yet, 
as  Lejars  says,  in  certain  cases  it  is  a  formidable  task  straining  the  re- 
sources of  the  most  practised.  It  is  an  idea  too  long  prevalent  that 
there  is  a  minor  and  a  major  surgery.  There  is  only  one  kind  of  good 
surgery,  whether  the  case  is  of  great  or  little  importance.  It  is  that 
which  recognizes  the  indications  and  meets  them  promptly,  giving  the 
patient  relief  with  the  least  possible  delay. 

Abscesses  have  too  much  been  regarded  as  simple  conditions  which 
the  merest  tyro  might  treat.  We  all  know  of  patients  who  have 
died  of  these  operations;  of  others  who  have  been  disabled  by  the  failure 
to  perform  them,  or  by  their  being  tardily  or  improperly  done.  And 
how  often  tardily  done! 

But  what  excuse  can  one  make  for  delay  after  pus  has  definitely 
formed,  for  any  attempt  to  bring  about  its  absorption  is  futile.  Delay 
merely  means  that  the  collection  augments,  destroys  more  tissues,  ac- 
quires diverticula  without  end,  which  may  need  to  be  opened  up  time 
and  time  again,  or  may  require  months  to  heal,  and  eventually  give 
rise  to  irremediable  contractions  and  adhesions. 

It  is  one  of  the  most  important  and  least  varying  rules  of  surgical 
practice  that  every  acute  abscess,  superficial  or  deep,  must  as  early 
as  possible  be  incised,  emptied,  and  drained. 

Another  point:  do  not  wait  for  fluctuation,  which  is  so  commonly 
the  practice.  If  the  suppuration  occurs  in  the  deeper  structures,  fluc- 
tuation  may  be  delayed.      But  there  are  ample  indications  otherwise; 


3*4 


ABSCESS. 


the  rapid  increase  of  swelling,  the  radiating  pains,  fever,  and  subcutane- 
ous edema  give  sufficient  evidence  that  pus  is  present. 

In  certain  regions,  the  thick  and  brawny  skin  and  fascia  is  as  signifi- 
cant as  fluctuation  itself.  On  the  scalp,  for  instance,  this  brawny 
edema  is  a  definite  symptom  of  suppuration.  In  the  belly  walls,  as 
Lejars  remarks,  the  consistency  of  a  deep  abscess  reminds  one  of 
sarcoma. 

The  edema  is  superficial;  the  suppuration,  deep.  The  two  processes 
go  together  and  when  the  first  is  present,  one  may  unhesitatingly  diag- 
nosticate the  second. 

To  repeat,  when  the  skin  pits  on  pressure  and  is  only  slightly  red- 
dened even,  the  diagnosis  is  no  longer  doubtful  and  one  may — one 
should — operate  at  once. 

The  length  of  the  incision  is  of  the  greatest  importance.  Nothing  is 
more  unsatisfactory  than  the  mere  stab,  or  puncture,  of  an  acute  abscess. 
The  incision,  cutting  through  the  middle,  parallel  with  the  most  im- 
portant structures,  should  open  up  the  whole  length  of  the  cavity. 
In  this  manner  no  pockets  are  left  behind,  and,  besides,  a  long,  smooth 
incision  will  in  the  end  leave  the  least  scar.  A  counter-incision  may 
be  necessary. 

Once  the  abscess  is  opened  and  the  pus  has  ceased  to  flow,  wipe 
out  the  cavity  with  sterile  gauze  and  irrigate  with  sterile  water  or  some 
antiseptic.  If  diverticula  are  found,  they  too  must  be  freely  opened  up 
and  irrigated. 

Insert  a  drain.  If  the  abscess  was  small  and  the  incision  made 
early,  it  is  proper  to  dispense  with  the  drain;  but  if  the  suppuration  is 
extensive,  the  best  means  of  preventing  large  scar  formation  is  to 
employ  drainage. 

Observe,  then,  says  Lejars,  that  the  whole  therapy  of  abscesses  is 
contained  in  these  two  words,  "empty"  and  "drain." 

You  do  nothing  more — there  is  nothing  more  to  be  done — and  it  is 
sufficient.  To  attempt  to  make  an  abscess  cavity  aseptic  is  wasted 
effort.  An  abscess  contains  infection  of  limited  virulence  and  when 
once  it  is  emptied,  the  living  tissues  will  do  the  rest,  provided  they  are 
not  embarrassed  by  new  germs  introduced  by  the  operation. 

With  this  notion  in  view,  then,  it  must  be  an  absolute  rule  of  practice 


TREATMENT    OF   CHRONIC   ABSCESS.  315 

to  operate  for  abscess  with  clean  hands  and  clean  instruments  in  a 
darefull)   disinfet  ted  field.     We  may  put  away  for  all  time  the  old 

dictum,  "  If  pus  is  present,  antisepsis  is  useless." 

I  disinfect  the  hands,  or  what  is  better,  the  gloves;  boil  the  instruments; 
cleanse  the  affected  area  with  soap  and  alcohol  and  bichloride;  then, 
and  then  only,  are  you  ready  to  incise  the  swelling.  Wipe  out  with 
■erile  gauze;  use  sterile  tubes.  Do  not  pack  with  gauze;  there  is 
nothing  more  illogical  than  tamponade  of  an  abscess  cavity.  Cover 
the  wound  with  sterile  gauze  and  absorbent  cotton,  and  bandage  firmly 
50  that  nothing  may  enter  the  wound;  so  that  the  dressings  will  not 
dip  or  rub. 

The  dressings  are  to  be  changed  daily  at  first  and  the  tubes  every 
second  or  third  day,  and  are  to  be  shortened  as  the  cavity  fills  up  with 
granulations;  are  to  be  dispensed  with  when  pus  has  ceased  to  form. 

Treatment  of  Cold  Abscess. — The  treatment  of  a  cold  abscess 
differs  from  that  of  an  acute  abscess  in  that  incision  is  not  the  method 
ff  choice. 

There  is  always  great  danger  of  infection  when  the  abscess  cavity 
is  opened  up  and  for  that  reason  incision  must  be  done  with  circum- 
spection— with  an  absolute  asepsis.  There  is  not  the  urgency  present 
n  the  acute  case. 

Puncture  is  the  method  of  choice.  Employ  the  strictest  antisepsis. 
Wash  with  soap  and  water,  but  not  too  vigorously  lest  the  abscess 
■all  be  ruptured;  complete  the  disinfection  with  alcohol  and  ether. 
pmploy  only  such  instruments  as  are  carefully  sterilized.  Use  a  trocar 
3f  sufficient  size  that  the  grumous  fluid  will  not  occlude  it.  Do  not 
juncture  the  summit  of  the  tumor  if  the  skin  is  quite  thin,  but  select  a 
K>int  where  the  tissues  are  sufficiently  resistant  to  close  when  the  trocar 
s  withdrawn.  At  the  end  of  the  evacuation  the  fluid  may  need  to  be 
■pirated.     It  may  be  discolored  bv  some  blood  from  the  puncture. 

Injection  with  some  stimulating  and  antiseptic  fluid  should  follow. 
Kthereai  solution  of  iodoform  has  the  advantage  of  distending  the  cavity 
>y  gas  formation  and  reaching  all  the  diverticula;  but  it  has  the  dis- 
ulvanlagc  thai  it  is  toxic.  Inject  5  to  ioc.c.  of  a  10  per  cent,  solution; 
cave  the  trocar  in  place,  (losing  its  orifice  with  the  finger.  When  the 
•avity  becomes  distended,  remove  the  linger  and  the  ether  spurts  out. 


316  ABSCESS. 

Let  all  the  gas  escape.     If  one  does  not  observe  this  rule  there  may  be  a 
slough. 

A  solution  of  iodoform  in  glycerine  may  be  employed;  inject  3  to  10 
grammes  of  a  10  per  cent,  solution,  letting  the  surplus  escape.  Cam- 
phorated naphthol  may  be  used  in  the  same  way.  Bismuth  paste  in 
certain  localities  serves  an  excellent  purpose.  After  the  injection 
is  completed  seal  the  puncture  with  collodion.  Several  injections  may 
be  necessary  for  a  cure.  Constitutional  treatment  is  of  the  greatest 
importance. 

ABSCESSES  OF  THE  SCALP. 

These  are  found  in  three  locations: 

1 .  Superficial — that  is,  above  the  aponeurosis  of  the  occipito-f ron- 
talis. 

2.  Subaponeurotic — that  is,  between  aponeurosis  and  the  perios- 
teum. 

3.  Subperiosteal — between  the  periosteum  and  the  bone. 

1.  Superficial  abscess,  due  to  staphylococci,  is  quite  localized, 
and  yet  very  painful  on  account  of  the  resistance  of  the  firm  tissue. 
The  lymph  nodes  behind  the  ear  and  in  the  back  of  the  neck  are 
enlarged  and  tender.  The  chief  danger  is  in  extension  to  the  deeper 
layers;  or  the  emissary  veins  may  carry  infection  to  the  sinuses  and 
produce  thrombosis  or  pyemia.  Evacuate  immediately  by  free  inci- 
sion, first  shaving  the  scalp  in  the  immediate  vicinity  of  the  abscess. 

Remembering  the  manner  in  which  the  occipital  and  temporal 
arteries  converge  toward  the  apex,  the  incision  may  be  managed  in  such 
a  way  as  to  run  parallel  to  the  small  vessels  distributed  to  the  area. 

The  cavity  must  be  kept  open  by  a  strip  of  rubber  tissue  or  a  small 
drainage-tube.  A  dressing  of  gauze,  absorbent  cotton  and  bandage 
complete  the  treatment.     Change  the  dressing  every  day  at  first. 

2.  Subaponeurotic  abscess  is  likely  to  follow  wound  infection. 
The  streptococci  follow  the  areolar  tissues  that  separate  the  aponeurosis 
from  the  periosteum,  and  the  spread  of  pus  is  limited  only  by  the  attach- 
ments of  the  aponeurosis.  Septicemia,  meningitis,  and  thrombosis  are 
the  actual  dangers,  and  on  these  accounts  immediate  operation  is 
demanded. 


n  ii  \i  I  i     OF   Tin     PACE.  317 

Make  a  free  incision  under  antiseptic  precautions;  that  is,  after 
shaving  and  cleansing  the  part  involved. 

Do  not  attempt  irrigations,  above  all,  in  these  cases,  for  the  fluid 

percolating  through  the  loose  areolar  tissues  spreads  the  infection. 
Good  drainage  alone  will  suffice.  The  dressings  must  be  changed 
frequently  at  first  and  must  be  firm  enough  to  prevent  movement  of 
the  occipito-frontalis  muscle. 

If  the  abscess  develops  under  the  temporal  fascia,  it  will  not  point 
toward  the  surface,  owing  to  the  extreme  density  of  this  fascia,  but  to- 
ward the  mouth  or  neck  through  the  ptergo-maxillary  fossa.  Even 
though  there  be  no  fluctuation  (usually  indeed,  none  can  be  detected), 
the  diagnosis  can,  nevertheless,  be  certainly  made  from  the  presence  of 
the  edema,  redness,  and  pain.  Make  a  vertical  incision  an  inch  or  so 
in  front  of  the  ear  and  with  the  center  about  the  level  of  the  eyebrow. 
It  may  be  necessary  to  go  through  the  substance  of  the  muscle  to  the 
bone.  A  few  small  arteries  will  be  divided  and  will  require  ligation. 
It  may  be  necessary  at  the  first  dressing  to  pack  the  cavity  with  gauze 
to  control  slight  but  persistent  bleeding.  Drainage  by  means  of  tubes 
nay  be  employed  subsequently. 

3.  Subperiosteal  abscesses  differ  from  the  others  in  that  they 
are  likely  to  be  the  result  of  bone  inflammation,  tubercular  or  syphilitic. 
The  abscesses  are  limited  to  the  area  of  one  bone  as  the  periosteum 
along  the  line  of  the  sutures  is  continuous  with  the  dura  mater.  This 
furnishes  an  easy  means  of  entrance  into  the  cranial  cavity  for  the 
infection  and  in  that  manner  meningitis  may  result.  For  this  reason, 
these  abscesses,  of  whatever  origin,  should  be  evacuated  at  once  and 
appropriate  constitutional  treatment  instituted. 

ABSCESS  AND  FURUNCLE  OF  THE  FACE. 

The  danger  in  these  conditions  is  that  phlebitis  beginning  in  the 
facial  vein  may  spread  to  the  cavernous  sinus,  so  free  is  the  communi- 
cation by  numerous  branches  between  these  venous  channels.  Espe 
Bally  to  be  feared  are  these  furuncles  beginning  on  the  upper  lip  or 
median  parts  of  the  face.  They  may  be  fatal  in  a  few  days.  Nearly 
always  the  staphylococcus  pyogenes  is  the  active  causative  agent  and 


318  ABSCESS. 

one  need  not  usually  be  at  a  loss  to  trace  the  mode  of  entrance  of  the 
infection. 

Early  incision  is  imperative  in  all  such  acute  septic  processes. 
The  best  form  of  local  anesthesia  in  these  conditions  is  by  freezing  with 
ethyl  chloride  spray.  Hypodermic  injections  are  best  avoided  here. 
The  incision  must  be  deep  to  be  effective,  and  in  making  it  two  factors 
are  to  be  borne  in  mind,  the  resulting  scar  and  injury  to  the  branches 
of  the  facial  nerve.  In  severe  cases  even  these  points  must  be  dis- 
regarded. Even  more  certain  than  free  incision  is  central  puncture 
with  a  fine  thermo-cautery,  followed  by  the  Bier  suction  treatment. 
If  it  is  a  carbuncle  of  the  diffuse  type,  accompanied  by  edema  of  the 
face  and  inflammation  of  the  viens,  crucial  incision  with  curettement 
must  be  undertaken.  The  dressing  of  gauze  may  be  held  in  place  by 
adhesive  strips. 

ABSCESS  OF  THE  NASAL  SEPTUM. 

Following  a  blow  upon  the  nose,  bleeding  ensues  and,  two  or  three 
days  later,  obstruction.  Looking  into  the  child's  nasal  fossae,  they  are 
seen  to  be  filled  with  a  bright  red,  tender,  fluctuating  swelling,  over  the 
cartilaginous  portion  of  the  septum.  The  whole  nose  becomes  hot, 
swollen,  and  painful. 

The  treatment  is  evacuation  by  a  free  incision  of  the  mucous  mem- 
brane over  the  septum  at  the  point  of  greatest  fluctuation. 

To  operate,  apply  a  4  per  cent,  solution  of  cocaine  to  the  mucous 
membrane,  and  after  waiting  a  minute  or  two,  make  an  incision  along 
the  septal  wall  from  above  downward  and  forward  with  a  slender,  sharp 
bistoury.  Douche  the  nasal  fossa  frequently  with  a  mild,  alkaline 
antiseptic.  Recovery  usually  follows  within  a  week,  although  in  the 
neglected  cases,  necrosis  of  the  cartilage  may  occur. 

ABSCESS  OF  THE  EYELIDS. 

The  loose  connective  tissues  of  the  eyelids  favor  exudation  and] 
edema.  An  abscess  occurring  here  is  usually  due  either  to  trauma- 
tism or  to  septic  infection  entering  from  the  face  or  scalp  or  to 
periostitis  of  the  margin  of  the  orbit.     Early  treatment  of  contusions 


I>1S(  hi  OB  ITIONS  O]     l  Hi     INI  LED.  3  ' ') 

may  prevent  not  only  the  unsightly  discoloration  ("black  eye"),  lint 

also  a  later  al>s<  ess. 

To  prevent  discolorations  apply  cooling  or  evaporating  Lotions  or 
wring  a  gauze  compress  out  of  ice  water  and  apply  to  the  lid,  renewing 
the  compress  every  two  or  three  minutes.  Do  not  allow  the  compress 
to  cover  the  nose,  else  a<  ute  coryza  may  result.  Apply  in  this  manner 
for  an  hour  and  repeat  every  second  or  third  hour  for  twenty-four  hours. 
A  solution  of  arnica  (2  oz.),  in  water  (1  pt.),  may  lie  applied,  or 

Ammonii  Chloride,  1 

Alcohol,  1 

Aquae,  10 

//  discoloration  appears,  apply  flannel  cloths  wrung  out  of  hot  water. 
for  an  hour  at  a  time,  three  or  four  times  daily,  and  follow  with  gentle- 
massage  for  five  to  ten  minutes.  Before  applying  the  heat  it  is  better 
to  smear  the  lid  with  vaseline.  Ointment  of  yellow  oxide  of  mercury 
is  excellent  to  use  with  massage.  If  an  abscess  appears  make  an  inci- 
sion parallel  with  the  muscle  fibers.  Apply  antiseptic,  absorbent 
dressings. 

ABSCESS  OF  THE  LACHRYMAL  GLAND. 

Abscess  of  the  lachrymal  gland  is  rare,  yet  doubtless  is  often  over- 
looked. It  is  seen  in  infancy,  usually  traceable  to  some  of  the  infectious 
diseases.  The  abscess  breaks  into  the  superior  cul-de-sac  and  re- 
covery follows. 

ABSCESS  OF  THE  EXTERNAL  AUDITORY  MEATUS. 

Abscess  of  the  external  meatus  is  extremely  painful  and  alarming, 
but  in  fact  not  particularly  dangerous.  The  meatus  is  closed  by  the 
swelling,  but  a  stab  with  the  point  of  the  knife  or,  if  it  is  more  deeply 
situated,  an  incision  in  the  direction  of  the  long  axis  of  the  meatus,  will 
cause  a  speedy  disappearance  of  the  symptoms,  (lentle  douching 
with  an  antiseptic  solution,  and,  after  drying,  occlusion  with  absorbent 
cotton,    will   soon   complete   the   cure. 


320  ABSCESS. 

ABSCESS  OF  THE  PAROTID  GLAXD. 

An  inflammation  begins  in  the  parotid  gland,  the  result  of  local 
infection  or  secondary  to  an  abdominal  disease  or  injur}7  (most  fre- 
quently involving  the  pancreas,  perhaps),  and  nearly  always  suppura- 
tion follows.  The  severe  forms  are  dangerous;  happily,  however, 
the  pus,  even  if  left  to  take  its  own  course,  works  its  way  to  the  surface 
or  points  at  the  pharynx.  It  may  burrow  down  to  the  anterior  medias- 
tinum. The  special  dangers  are  meningitis,  septic  poisoning,  and 
thrombosis.  When  the  swelling  is  great,  pressure  interferes  with 
the  venous  current  and,  as  a  result,  cerebral  congestion,  headache, 
and  finally  delirium  ensue.  The  pus  may  open  into  the  middle  ear 
and  infection  by  that  route  reaches  the  brain.  Suppuration  of  the 
temporo-maxillary  articulation  may  follow. 

Treatment. — If,  when  the  swelling  first  appears,  a  probe  be  passed 
into  Stenson's  duct  and  the  gland  be  pressed  from  the  outside,  a  few 
drops  of  pus  may  be  squeezed  out  and  this  may  serve  to  head  off  a 
general  suppuration.  If  the  entire  gland  becomes  involved,  hot  anti- 
septic poultices  should  be  applied  to  hasten  the  localization  of  the  pus. 
As  soon  as  redness  and  edema  indicate  the  most  probable  situation  of 
the  pus,  an  effort  must  be  made  to  evacuate  it.  Several  important 
structures  are  to  be  avoided;  Stenson's  duct  (a  fistula  is  likely  to 
follow  its  division),  the  facial  nerve,  the  carotid  arteries,  the  temporo-' 
maxillary  vein  and  other  vessels  of  lesser  importance  may  be 
wounded. 

If  the  anterior  part  of  the  gland  is  involved,  the  incision  is  made 
parallel  with  and  below  Stenson's  duct.  The  skin  and  fascia  are 
divided  and  retracted  and  an  effort  is  made  to  burrow  into  the  depths 
of  the  gland  with  a  probe  or  grooved  director.  The  pus  follows  the 
connective  tissue  lamina;  instead  of  the  lobules  of  the  gland,  and  it  is 
better,  if  possible,  to  avoid  dividing  the  grandular  substance.  If 
the  posterior  and  lower  part  of  the  gland  is  involved,  the  incision  should 
be  vertical,  with  its  center  a  little  above  and  anterior  to  the  angle  of 
the  jaw.  The  temporo-maxillary  vein  will  be  seen,  running  parallel  i 
to  the  incision  near  the  surface  of  the  gland.  A  drainage-tube  must 
be  left  in  the  deeper  abscesses. 


TR]  \  I  Ml  N  I    "i     I'l  \  l  \T.   ABSi 


321 


l»l\  lAL  ABSCESS. 

These  painful  affections  are  not  to  be  neglected,  for  they  may  lift 
up  the  periosteum  and  result  in  necrosis  of  the  jaw.  Left  to  itself, 
the  abscess  may  point  in  the  mouth,  less  frequently  on  the  face.  It 
begins  in  the  alveolar  process  from  infection  from  a  carious  tooth. 
It  makes  its  appearance  at  the  junction  of  the  cheek  and  the  gum.  In- 
spection and  palpation  make  the  diagnosis.  A  cotton  tampon  soaked 
in  2  per  cent,  cocaine  solution  is  laid  on  the  gum  for  five  or  ten  minutes, 
but  analgesia  will  not  be  complete.     Lift  the  cheek  away  from  the 


M.H. 


Pig.  ^43. — Dental  abscess. 

(Tt-JK.) 


j  /I 


Fig.  244. — Submaxillary  abscess 
in  contact  with  inner  surface  of 
the  inferior  maxilla.  M.  H., 
Mylohyoid  muscle.  P.,  Platysma 
myoides.  GLs.M.,  Submaxillary 
gland.     (Veau.) 


gum  as  far  as  possible,  and  with  a  sharp-pointed  bistoury,  wrapped  to 
within  a  half-inch  of  the  point,  make  a  horizontal  incision  and  cut 
down  to  the  bone.  There  is  nothing  to  fear  and  without  getting  deep 
one  may  fail.  The  patient  may  resist  further  efforts  or  the  field  may 
be  obscured  by  blood  (Fig.  243). 

Order  an  antiseptic  mouth-wash  (peroxide  or  glyco-thymoline,  etc.) 
to  be  used  every  half-hour  at  first  and  the  pain  will  rapidly  disappear. 
In  more  extensive  subperiosteal  abscess  of  the  jaws,  the  same  principle 
of  procedure  should  be  carried  out. 


322 


ABSCESS. 


SUBMAXILLARY  ABSCESS. 

Do  not  await  fluctuation  in  acute  inflammations  in  this  locality. 
The  pain,  augmented  by  pressure,  the  brawny  edema  and  diffuse 
redness  are  sufficient  to  demonstrate  the  presence  of  pus.  The  pus  is 
not  always  easy  to  find,  for  it  is  deep,  often  subperiosteal  and  in  con- 
tact with  the  internal  surface  of  the  jaw,  and  is  generally  due,  in  fact, 
to  dental  infection  (Fig.  244) 


Fig.  245. — 


Incision  of  submaxillary  abscess.     Dotted  line  represents  the 
facial  artery.      (Veau.) 


Local  anesthesia  is  often  sufficient.  Locate  the  angle  of  the  jaw. 
This  is  often  difficult  on  account  of  the  edema.  A  finger's  breadth 
below,  and  following  the  body  of  the  jaw,  make  a  curved  incision 
(Fig.  245)  with  slight  downward  convexity  about  three  inches  in  length. 
Remember  the  point  at  which  the  facial  artery  crosses  the  body  of! 
the  jaw,  just  in  front  of  the  masseter.  Do  not  cut  deeper  than  the] 
skin,  for  this  is  dangerous  ground.  Now  dissect  with  forceps  andl 
grooved  director  the  subjacent  tissues,  making  haste  slowly  and  re- 


ludwig's  angina. 


3*3 


Dewing  from  time  to  time  the  analgesia  or  injections  as  the  patient 
complains  of  pain. 

Can-)'  the  dissection  upward  and  inward  toward  the  inner  surface 
of  the  jaw,  and  with  patience  the  abscess  will  be  located.  As  it  is 
approached,  the  tissues  will  be  found  more  and  more  edematous  and 
idled  with  serum.  Having  once  cut  into  it,  enlarge  the  opening,  always 
too  small,  by  introducing  and  opening  an  artery  forceps.     Irrigate 


//  ff 


I'n..  246. — Phlegmon  of  the  floor  of  the 
mouth.  The  tongue  is  pushed  to  the  oppo- 
site side  and  the  spread  downward  of  the 
purulent  collection  opposed  by  the  mylo- 
hyoid muscle.  GSL,  sublingual  gland.  AL, 
lingual  artery.  CW ,  salivary  duct.  GGL, 
genio-hyo-glossus.  GY ,  genio-hyoid.  MY., 
nyo-glossus.     D,  digastric.     {Veau.) 


I"ir..    247.  —  Incision    for   phlegmon   of 
floor  of  mouth.     (Veau.) 


with  sterilized  water,  insert  one  or  two  small  drains,  dress  with  an- 
tiseptic gauze  and  absorbent  cotton,  and  renew  daily.     The  tempera 
turc   will  fall   rapidly.     After   five  or  six  days   the  drainage   may   be 
diminished  and  after  ten  days  entirely  removed. 

ABSCESS     OF  THE  FLOOR  OF  THE  MOUTH. 
(Ludwig's    Angina.) 

This  is  a  very  grave,  usually  fatal  condition,  originating  in  strepto- 
coccic infection  through  the  mucous  membrane  of  the  floor  of  the 
mouth.  It  more  frequently  occurs  in  adults,  though  childhood  is  not 
exempt.     Its  tenden<  \  is  10  extend  into  the  uei  k,  following  the  cellular 


324  ABSCESS. 

planes,  and  if  the  patient  does  not  die  early  from  septicemia,  gangrene 
may  occur.  In  a  very  few  hours  after  the  infection  begins,  the  floor 
of  the  mouth  becomes  brawny,  the  tongue  is  thrust  up  against  the 
hard  palate,  and  breathing  and  swallowing  markedly  interfered  with. 
If  anything  is  to  do  good,  it  must  be  done  at  once  (Fig.  246). 

Try  the  antistreptococcic  serum — if  it  does  no  good,  it  will  at  least 
do  no  harm.  In  the  meantime,  operate.  Frequently  a  general  anes- 
thesia is  indispensable.  Make  van  incision  a  finger's  breadth  below 
the  body  of  the  jaw  about  three  inches  long  so  that  it  reaches  beyond 
the  median  line  (Fig.  247).  If  both  sides  are  equally  involved,  make 
a  bilateral  incision.     One  may  perhaps  recognize  the  platysma,  but 

MX 


Fig.  248. — Deep  incision  for  phlegmon  in  floor  of  mouth.     G.s.M.,  submaxillary 
gland.     M.H.,  mylo-hyoid  muscle.     D,  digastric  muscle.      (Veau.) 

the  anterior  belly  of  the  digastric  must  be  demonstrated  and  divided. 
Next  expose  the  mylo-hyoid  and  divide  completely  (Fig.  248).  Hav- 
ing now  reached  the  sublingual  space,  you  may  find  merely  a  serous 
exudate,  characteristic  of  this  form  of  infective  inflammation.  Do  not 
stop  until  the  mucous  membrane  of  the  mouth  has  been  demonstrated, 
for  otherwise  one  may  mistake  the  submaxillary  for  the  sublingual 
gland  and  not  go  deep  enough. 

Douche  thoroughly  with  peroxide,  place  two  or  three  large  drainage- 
tubes,  pack  with  gauze  saturated  with  peroxide,  and  apply  absorbent 
cotton.  Renew  the  dressings  and  flushing  three  or  four  times  daily  and 
the  serum  injections  as  well.  Possibly  the  patient  will  go  on  rapidly 
to  death  from  septicemia.  He  is  almost  certain  to  do  so  without  the 
operation.  The  drainage  may  be  diminished  toward  the  tenth  day. 
Several  weeks  will  be  required  for  a  cure. 


TONSILLAH    Ai-.sn  ss.  325 

ABSCESSES  OF  THE  TONGUE. 

Abscesses  of  the  tongue  do  not  often  occur,  but  when  they  do,  may 
give  rise  to  urgent  conditions.  They  may  develop  suddenly  with  much 
pain,  which  may  be  variously  reflected — to  the  ear,  for  example. 

The  tongue  may  be  so  swollen  as  to  fill  the  mouth  and  severely  dis- 
turb respiration.  The  location  of  the  abscess  is  to  be  determined  by 
palpation.  If  it  is  at  the  base  of  the  tongue  and  pointing  toward  the 
surface,  it  is  to  be  evacuated  by  a  median  longitudinal  incision  from 
behind  forward  and  deep  enough  to  reach  the  pus.  There  is  no  danger 
of  wounding  important  structures  if  the  incision  follows  the  middle 
line.  Leave  a  strip  of  gauze  in  the  wound  for  drainage.  Prescribe 
frequent  antiseptic  mouth-washes.  If  the  abscess  lies  under  the  tongue 
and  points  downward,  the  incision  must  be  made  along  the  floor  of 
the  mouth,  if  the  mouth  can  be  sufficiently  opened  and  fluctuation  de- 
tected. The  ranine  artery  may  be  wounded.  If  the  mouth  cannot 
be  opened  it  is  best  to  operate  from  the  outside,  making  a  median 
vertical  incision  from  the  symphysis  of  the  chin  down,  getting  between 
the  two  genio-hyo-glossi  muscles  and  following  this  crevice  up  to  the 
under  surface  of  the  tongue.  Drainage-tube,  antiseptic  absorbent 
dressing. 

TONSILLAR  ABSCESS. 

"Ouinsy"  is  an  acute  suppuration  in  the  tonsil  or  around  the  tonsil 
following  acute  infection  of  the  gland. 

Often  the  suppuration  occurs  only  on  one  side,  though  both  tonsils 
are  inflamed.  At  any  rate  the  two  tonsils  do  not  suppurate  simulta- 
neously. 

The  temperature  is  high,  the  pain  extreme,  there  is  difficulty  in 
Swallowing  and  perhaps  in  breathing.  There  may  be  edema  of  the 
glottis.  Often  there  is  difficulty  in  opening  the  jaws.  After  the  ab- 
scess is  well  formed  the  soft  palate  is  edematous  and  swollen. 

Pus  begins  to  form  about  the  third  day  after  the  attack.  Previous 
to  this  an  effort  should  be  made  to  abort  the  abscess.  Give  calomel 
in  small  frequent  doses  and  follow  with  a  saline  purge,  and  in  the  mean- 
time administer  full  doses  of  sodium  salicylate.     I'henacetine,  two  or 


326 


ABSCESS. 


three  grains  frequently,  will  make  the  patient  more  comfortable. 
Paint  the  tonsils  and  pharynx  with  argyrol  once  a  day  and  use  the 
peroxide  spray  (50  per  cent,  solution)  every  two  or  three  hours.  Ap- 
ply hot  antiseptic  fomentations  or  poultices  externally. 

If  these  measures  fail  to  relieve  the 
symptoms  after  the  third  day,  it  is 
almost  certain  that  pus  has  formed,  even 
though  fluctuation  cannot  be  felt,  and  it 
is  best  to  make  an  incision,  but  this  must 
be  free. 

The  operation  is  sometimes  difficult. 
A  general  anesthesia  will  be  necessary 
if  the  jaws  are  locked.  Open  the 
mouth  wide.  A  mouth  gag  is  often 
necessary.  Depress  the  tongue  as  much 
as  possible.  Swab  the  tonsil  with  a  10 
per  cent,  solution  of  cocaine.  With  a 
sharp  pointed  bistoury  (wrapped),  make 
an  incision  in  the  soft  palate  just  ex- 
ternal to,  and  parallel  with,  the  anterior 
pillars  and  extending  as  low  down  as 
possible.  If  the  pus  flows  freely,  some  of  it  may  be  swallowed,  to  pre- 
vent which  bend  the  head  down.  Continue  the  spray  and  antiseptic 
mouth-washes  for  a  few  days.  Whether  pus  is  located  or  not,  free 
incision  gives  great  relief  (Fig.  249). 


Fig.  249. — Tonsillar  abscess.  In- 
cision should  extend  as  low  as  possi- 
ble.     {Veau.) 


RETROPHARYNGEAL  ABSCESS. 


These  conditions  are  treacherous  and  dangerous  because  (most 
frequent  in  infants)  they  may  be  overlooked  and,  bursting  into  the 
pharynx,  may  produce  suffocation. 

The  pharynx  is  separated  from  the  muscles  covering  the  anterior 
surface  of  the  bodies  of  the  cervical  vertebrae  by  a  loose  connective 
tissue.  One  or  two  lymphatic  glands  lie  in  front  of  the  bodies  of  the 
upper  two  cervical  vertebras  en  either  side  of  the  middle  line.  These 
receive  lymph  (and  infection)  from  the  nasal  cavities  and  their  acces- 


ft]    I  RO   I'll  \KN  Net    \l.     \|.-(   I  SS.  327 


sory  sinuses,  the  naso  pharynx,  the  Eustachian  tube,  the  tympanum, 
ami  Erom  the  tissues  lying  on  the  bodies  of  the  adjacenl  vertebrae. 
Septic  conditions  existing  in  any  of  these  localities  may  be  the  sour<  e  of 
the  inflammation  of  these  Ij  mph  glands,  which  may  end  in  suppuration. 
These  glands  empty  by  several  chains  of  lymph  vessels  into  the  deep 
cervical  glands. 

The  suppuration  begins  <>n  one  side  usually,  but  rapidly  spreads 
toward  the  middle  line,  where  the  tissues  are  loosest.  The  ab 
may  l>e  behind  the  palate;  it  may  be  opposite  the  larynx;  in  either  case 
almost  out  of  sight.  Usually,  however,  it  is  seated  in  the  posterior  wall 
of  the  pharynx,  opposite  the  oral  cavity.  When  situated  there,  ii 
rise  to  fewest  symptoms,  and  for  that  reason  its  development  is  in- 
sidious, and  in  the  infant  unsuspected.  The  constitutional  disturb- 
ance may  be  slight. 

Obstructed  breathing  and  hoarseness  and  a  feeling  of  tightness  in  the 
throat  may  first  suggest  the  difficulty.  Inspection  and  palpation,  al- 
ways necessary,  are  not  always  easy  and,  in  the  case  of  infants,  some- 
times dangerous.  Still,  only  by  touch,  with  the  finger  in  the  mouth, 
can  the  exact  condition  be  determined.  To  prevent  asphyxia  or 
syncope,  the  main  thing  is  to  be  rapid  in  the  examination.  To  facili- 
tate this,  the  child  must  be  prepared. 

It  is  seated  on  the  assistant's  lap  with  its  face  turned  to  the  light, 
its  arms  and  body  encircled  by  a  towel,  its  legs  held  firmly  between  the 
assistant's  knees.  Its  mouth  is  forced  open  by  pressing  the  cheeks 
between  the  teeth.  The  finger  is  passed  to  the  back  of  the  tongue  and 
rapidly  palpates  the  walls  of  the  pharynx.  It  is  not  difficult  to  deter- 
mine the  point  of  greatest  swelling. 

Operation. — 1.  Have  already  prepared  a  sharp-pointed  bistoury 
wrapped  with  cotton  close  up  to  the  point.  The  index  linger  in  the 
mouth  holds  the  tongue  down  and  the  bistoury  is  passed  along  the 
finger  and  plunged  into  the  abscess  in  the  middle  line,  that  no  blood 
vessels  may  be  injured.  This  puncture  is  prolonged  into  an  incision 
from  above  downward  at  least  an  inch;  in  fact,  as  low  as  possible,  that 
chances  of  a  recurrence  may  be  diminished.  The  patient  is  imme- 
diately inclined  forward  in  order  that  the  pus  may  pour  out  of  the 
mouth  (Fig.  250). 


328 


ABSCESS. 


If  syncope  or  spasm  of  the  larynx  occurs,  do  not  lose  your  head,  but 
proceed  hastily  to  revive  the  patient  by  the  ordinary  means.  Lower 
the  patient's  head,  pull  out  the  tongue,  and  employ  artificial  respiration. 

As  after-treatment,  direct  frequent  irrigations  or  gargling  with 
sterilized  water.  A  peroxide  spray  may  be  used  with  good  effect. 
Recovery  occurs  within  a  few  days. 

If  the  abscess  recurs,  or  in  the  first  place  is  situated  too  far  down  for 
oral  puncture  (which  may  sometimes  be  done  by  passing  a  curved 


Fig.  250. — Retropharyngeal  abscess.     (Veau.) 


director  over  the  base  of  the  tongue  and  then  downward  to  the  top  of 
the  abscess),  or  the  jaws  are  locked,  it  will  have  to  be  reached  from  the 
side  of  the  neck,  an  operation  much  more  difficult  in  every  way. 

Operation. — 2.  Turn  the  patient  slightly  to  one  side,  resting  the  neck 
upon  a  cushion  to  make  its  lateral  aspect  prominent;  the  sterno-mas- 
toid  is  the  guide.  Make  an  incision  about  two  inches  in  length  along 
the  posterior  border  of  the  sterno-cleido-mastoid,  which  is  exposed 
after  the  skin  and  fascia  are  divided.     Ligate  the  veins;  avoid  the 


IBS<  I  ss   in     I  hi     (i  i:\  [(  \i    <.l  VNDS. 

superficial  cervical  nerves;  pull  the  sterno  cleido  mastoid  forward  and 
locate  the  scalenus  anticus.  Stick  t<>  the  scalenus  anticus,  follow  its 
anterior  surface  inward,  displacing  forward  by  careful  dissection  with 
grooved  director,  the  common  sheath  of  the  great  vessels  and  pneumo- 
kastric.  The  connective  (issue  are  rather  loose;  the  dissection  is  not 
difficult.  Be  on  the  watch  for  the  spinal  accessory  nerve,  which  lies  or 
the  deep  surface  of  the  sterno  mastoid.  Working  inward  in  this 
manner  reach  the  outer  border  of  the  longus  colli  which  lies  in  the  same 
Uane  as  the  scalenus  anticus,  and  upon  which  lies  the  pharynx  and  the 
Lbscess.  After  opening  and  emptying,  a  drain  must  be  left.  Employ 
the  usual  dressings  and  after-treatment.  Sometimes  the  abscess  lies 
further  forward  and  it  will  be  necessary  to  go  in  front  of  the  sterno- 
cleidomastoid. After  the  skin  and  fascia  are  divided,  the  finger  in 
the  wound  will  be  able  to  locate  fluctation  and  that  will  he  the  best 
guide  in  the  subsequent  dissection.  It  may  be  necessary  to  ligate 
several  small  veins.  Retract  the  anterior  border  of  the  sterno-mastoid 
and  with  it  the  sheath  of  the  common  carotid,  the  internal  jugular  and 
pneumogastric;  draw  forward  the  thyroid,  the  larynx  and  trachea. 
The  fascias  are  divided  by  blunt  dissection  until  the  abscess  cavity  is 
Opened. 

ABSCESS  OF  THE  GLANDS  OF  THE  NECK. 

Acute  suppuration  of  the  lymph  glands  of  the  neck  is  quite  frequent 
and  originates  in  infective  disorders  of  the  areas  drained  by  the  glands. 

In  treating  these  conditions,  the  source  of  the  infection  must  not  he 
overlooked.  It  is  not  always  advisable  to  operate  immediately,  even 
■hough  suppuration  is  believed  to  be  present,  unless,  of  course,  the 
inh  <  tion  shows  a  tendency  to  become  general. 

In  the  ordinary  case,  the  pus  may  be  \ cry  deeply  located  or  outside 
the  i  apsule  of  the  gland.  It  is  better  under  these  circumstances  to  apply 
hot  antiseptic  poultices  for  twenty-four  to  forty-eight  hours.  The  whole 
gland  then  becomes  softened,  the  pus  is  easily  evacuated  and  healing 
m  i  urs  rapidly;  whereas  a  dob  suppurating  gland  cut  into  may  remain 
enlarged  and  indurated.  Free  iin  ision  is  always  out  oi  the  question  as 
the  many  important  structures  of  the  neck  have  to  In-  borne  in  mind. 
Use   local    anesthesia.      In    making   the    in,  ision    it   is   usually   best    to 


330  ABSCESS. 

follow  the  posterior  border  of  the  sterno-mastoid.  Make  an  incision 
about  two  inches  in  length.  When  the  muscle  is  reached,  draw  it 
forward  with  a  retractor  and  with  a  grooved  director  search  for  the  pus 
cavity;  drain;  use  absorbent  dressings. 

CHRONIC  SUPPURATION  OF  THE  CERVICAL  GLANDS. 

There  are  various  clinical  manifestations  of  the  tubercular  processes, 
each  of  which  demands  a  somewhat  different  treatment.  It  is  as- 
sumed that  the  pus,  gradually  accumulating,  has  burst  through  the 
fascia  and  has  begun  to  bulge  the  skin. 

It  is  best  to  operate  at  once.  The  most  careful  asepsis  should  be 
maintained.  The  pus  is  evacuated  by  free  incision  and  the  abscess 
cavity  wiped  out  with  iodoform  gauze.  A  10  per  cent,  solution  of 
iodoform  emulsion  with  glycerine  is  poured  into  the  cavity  (two  or 
three  drachms  are  sufficient)  and  the  wound  sutured  and  treated  as  an 
aseptic  wound,  provided  there  is  no  evidence  of  secondary  infection. 

ABSCESS  OF  THE  BREAST. 

Abscess  of  the  breast  may  be  either  parenchymatous,  originating  in 
the  substance  of  the  gland;  or  submammary,  originating  in  the  areolar 
tissues  separating  the  gland  from  the  pectoralis  major. 

In  either  case  infection  nearly  always  begins  at  the  nipple  and  follows 
the  lymph  vessels  downward.  The  first  form  is  usually  due  to  staphy- 
lococcic infection,  the  second  to  streptococcic.  These  conditions  are 
preventable  in  the  greater  number  of  cases  and  for  that  reason  the 
nipple  should  be  given  special  care  both  before  confinement  and  during 
the  first  weeks  of  lactation. 

Even  when  the  breast  becomes  "caked"  and  tender  and  there  is  a 
little  fever,  antisepsis  at  the  nipple  and  hot  antiseptic  poultices  to  the 
breast  may  prevent  abscess  formation.  Continued  rise  in  temperature, 
slight  chills,  edema  and  pain,  more  or  less  localized,  indicate  the  for- 
mation of  pus,  and  immediate  operation  is  necessary.  A  general 
anesthesia  is  best  for  thoroughness,  though  the  work  may  be  done 
under  local  anesthesia. 


Aiisri  SS   <  >  I     I  hi     BR]  \si  .  331 

ruder  rigid  .isepsis,  proceed  to  open  up  the  cavity,  and  always  re- 
Blember,  the  earlier  the  better.  An  incision  an  inch  or  so  long  should 
Begin  near  the  nipple  and  radiate  from  it,  as  (he  spoke  from  the  hub 
)f  a  wheel.  In  this  manner  the  least  possible  Dumber  of  the  milk 
ducts  and  vessels  are  divided  (Fig.  251). 

The  first  incision  goes  through  the  skin  and  fascia  and  then  the  ab- 
scess cavity  is  sought  for  by  blunt  dissection  with  a  grooved  director. 
Still  there  is  nothing  to  fear  in  cutting  boldly  down  to  the  abscess. 
Explore  the  cavity  thoroughly  for  there  may  be  pockets  leading  off 


-1 

PlG.  -'Si. — Abscess  of  the  breast:   incision.      (Lejars.) 


from  the  main  cavity.  Do  not  neglect  this  point.  If  it  extends  deep, 
make  a  counteropening  at  the  base,  being  guided  by  the  director  in- 
troduced through  the  first  opening  (Fig.  252).  Pushing  a  forceps 
through  the  channel,  it  seizes  a  drainage-tube  which  is  drawn  into  place 
as  the  forceps  is  withdrawn.  Dress  with  antiseptic  gauze,  which 
should  be  changed  twice  daily  at  first,  care  being  taken  not  to  dis- 
turb the  drainage  tube. 

If  the  temperature  rises  again  after  the  second  or  third  day.  you  will 
lave  to  re  explore.  A  new  abscess  is  in  process  of  formation.  After 
five  or  six  days  replace  the  first  drainage  tube  with  a  smaller  one.     The 


332  ABSCESS. 

drainage-tube  can  be  entirely  dispensed  with  after  ten  days  or  two 
weeks. 

The  submammary  abscess  develops  without  edema  or  redness  be- 
cause it  underlies  the  whole  breast.  The  condition  can  scarcely  be 
mistaken,  for  the  marked  elevation  of  the  whole  breast,  along  with  the 
constitutional  symptoms  point  to  the  nature  of  the  trouble.  Make  a 
curved  incision  following  the  base  of  the  breast  at  its  lowest  part,  di- 
viding'the  skin  and  fascia.     With  a  grooved  director,  dissect  through 


Fig.  252. — Abscess  of  the  breast.     Manner  of  making  counteropening.     D,  grooved 
director;  P,  its  point;  B,  bistoury  cutting  down  on  to  the  point  of  director.      (Lejars.) 

the  areolar  tissues  between  the  gland  and  the  chest  wall,  working 
toward  the  center  of  the  breast.  These  deep  tissues  are  likely  to  be 
infiltrated.  In  this  manner  the  pus  is  evacuated  and  the  subsequent 
treatment  will  be  practically  the  same  as  that  prescribed  for  the  pre- 
ceding form. 

AXILLARY  ABSCESS. 

Three  chains  of  lymphatic  glands  are  found  in  the  axillary  space. 
One  lies  along  the  anterior  fold  of  the  axilla  and  drains  the  anterior 
thoracic  region;  one  lies  on  the  posterior  axillary  wall  and  drains  the 


Will  AKV     \l:-<   I  SS. 


333 


posterior  thoracic  region;  one  Lies  alongside  and  externally  is  connc  ted 

with  the  axillary  vessels  and  drains  the  upper  extremity.  Axillary 
ftbscess  usually  results  from  inflammation  <>f  one  or  the  other  of  these 
chains  of  glands,  the  infective  agent  having  been  carried  to  them  from 
a  distant  point,  such  as  the  breast  or  hand,  by  the  lymph  vessels. 

The  inflammation  spreads  from  the  glands  to  the  adjacent  areolar 
tissue  and  pus  formation  follows.  Abscess  may  also  form  by  exten- 
sion of  pus  formation  from  the  base  of  the  neck. 

The  most  frequent  sources  of  infection,  probably,  are  the  breast  and 
the  sebaceous  glands  in  the  skin  of  the  armpit.     Abrasions  and  small 


Pig  »S3.  Cross  section  showing  relations  of  axillary  abscess.  G.  F.  Pect.  major. 
P.P.  Feet,  minor.  G.  D.  Latiss,  dorsi.  S.SC.  Subscapularis.  G.  D.  Serratus  mag- 
nus.     (Veau.) 

boils  in  this  locality  must  be  treated  with  circumspection,  lest  they 
terminate  finally  in  axillary  abscess.  The  ordinary  symptoms  of  in- 
flammation and  pus  formation,  added  to  the  painful  abduction  of  the 
arm,  indicate  the  nature  of  the  trouble. 

It  is  imperative  to  evacuate  the  pus  promptly  for  the  reason  that  it 
pay  burrow  in  various  directions,  usually  upward  toward  the  neck. 
Tin-  axillary  vessels  may  be  eroded. 

The  incision  will  depend  upon  the  location  of  the  pus  thai  is  to  say, 
whether  it  lies  under  the  pectoralis  major  or  in  the  loose  areolar  tissues 


334 


ABSCESS. 


of  the  center  of  the  space.     Acute  abscess  more  often  lies  in  the  first 
locality  (Fig.  253);  tubercular  abscess  in  the  latter. 

(a)  Acute  Abscess  (Fig.  254). —General  anesthesia;  place  the 
patient  on  his  back;  abduct  the  arm  as  much  as  possible;  and  locate  the 
border  of  the  pectoralis  major.  Make  an  incision  three  inches  in  j 
length  along  this  line,  cutting  toward  the  thorax;  expose  the  muscle 
border  well;  dissect  along  the  under  surface  of  the  pectoralis  major 
with  the  grooved  director.     In  this  manner  you  keep  in  front  of  the 


Fig. 


254. — Incision  for  acute  axillary  abscess.     The  blunt  dissection  should  follow 
the  anterior  axillary  wall.      (Veau.) 


great  vessels  and  nerves  and  will  feel  secure.     When  the  pus  once 
flows,  enlarge  the  opening,  and  insert  drainage-tubes. 

To  avoid  the  axillary  structures,  you  must  keep  these  two  points 
in  mind:  (1)  Make  the  opening  large  enough  to  see  what  you  are 
doing — a  blind  stab  in  this  region  is  exceedingly  dangerous;  (2)  stick 
to  the  pectoralis  major — the  pus  is  in  contact  with  its  deep  surface. 
Wash  out  the  cavity  and  place  two  drains;  use  a  gauze  and  absorbent 
cotton  dressing  daily  for  a  week,  after  which  remove  the  tubes,  though 
the  external  opening  must  not  be  allowed  to  close  until  the  cavity  isj 
eliminated. 

(b)  Chronic  Abscess. — Incision.     Begin  in  the  middle  of  the  floor 
of  the  space  and  follow  the  middle  line  away  from  the  arm  toward  the > 


PALM  VB    \i;s<  i  ss.  335 

chest.  In  this  direction  alone  Is  -afeiy.  In  front  arc  the  long  thoracic 
vessels;  la-hind  are  the  subscapular  vessels;  to  the  outside  arc  the  main 
axillary  vessels  and  branches  of  the  brachial  plexus.  The  skin  im  is 
ion  may  occasionally  divide  a  small  artery,  which  will  at  first  give  some 
concern.  It  is  best  to  divide  the  connective  tissues  layer  by  layer  in 
the  original  line  of  incision.  There  is  no  danger  if  you  keep  in  this 
line.  Otherwise,  the  pus  may  be  reached  by  Hilton's  method.  After 
the  skin  and  fascia  are  divided,  a  dressing  forcep  is  pushed  up  into  the 
abscess  cavity  and  the  blades  opened.  Put  in  a  drainage-tube;  use 
absorbent  dressings;  maintain  a  careful  asepsis  throughout  the  process 
of  repair. 

PALMAR  ABSCESS. 

These  are  always  serious  conditions,  not  alone  on  account  of  sepsis, 
but  because  the  hand  may  be  left  permanently  crippled  or  useless  as  a 
result  of  the  destruction  of  tissue  and  inflammatory  adhesions. 

Immediate  evacuation  of  pus  is  imperative.  If  the  pus  is  limited 
to  the  connective  tissues  of  the  palm,  has  not  reached  the  tendon 
sheaths,  the  incision  should  be  made  over,  and  parallel  with,  the  in- 
terosseous space  in  the  region  of  the  greatest  swelling. 

If  the  tendon  sheaths  are  involved,  the  incision  should  be  made  in 
the  long  axis  of  the  metacarpal  bone  (seePIilegnimi,  page  362).  Whether 
the  condition  is  a  diffuse  inflammation  (phlegmon)  or  an  abscess  will 
be  determined  by  the  history  of  the  case. 

In  the  case  of  abscess,  make  a  longitudinal  incision.  The  palmar 
lurches  are  chiefly  to  be  considered.  Begin  the  incision  just  below  a 
line  drawn  across  the  palm  from  the  web  of  the  thumb.  Beginning 
Bearer  the  wrist,  the  superficial  palmar  arch  or  the  deep  arch  as  well 
may  be  divided.  Cut  toward  the  finger,  making  the  incision  suffi- 
ciently deep  to  go  quite  through  the  palmar  fascia.  Insert  a  drainage- 
tube.  Use  antiseptic  dressings,  changing  the  dressings  daily.  (See 
also  Phlegmons.) 

POPLITEAL  ABSCESS. 

Situated  in  the  hollow  back  of  the  knee-joint  in  the  superficial  fa- 
cia are  a  few  lymph  glands  which  may  suppurate  following  an  infci  li\e 


336  ABSCESS. 

process  in  the  foot  or  leg.  Situated  still  deeper  beneath  the  deep 
fascia  are  other  glands  which  may  similarly  suppurate. 

These  may  be  described,  then,  as  superficial  abscess  and  deep  ab- 
scess of  the  popliteal  space. 

The  superficial  abscess  may  be  opened  simply  by  a  vertical  incision 
over  the  point  of  greatest  swelling.  There  are  no  important  structures 
likely  to  be  wounded  by  a  superficial  incision. 

It  is  quite  different  with  a  deep  abscess.  The  situation  of  a  number 
of  important  structures  must  be  borne  in  mind.  In  the  center  of  the 
lower  half  of  the  space  lies  the  short  saphenous  vein;  to  the  outer  side 
lies  the  external  popliteal  nerve,  and  running  vertically  through  the 
center  of  the  space,  and  deeply  located,  are  the  popliteal  vessels  and 
internal  popliteal  nerve.  The  space  is  roofed  over  by  the  dense 
popliteal  fascia  which  is  the  chief  factor  in  determining  the  direction  in 
which  the  suppuration  extends;  thus  the  pus  is  more  likely  to  point  up 
in  the  thigh  or  down  in  the  leg  than  in  the  integuments  of  the  space. 

A  popliteal  abscess  may  likewise  be  the  result  of  the  extension  of 
a  suppurative  process  in  the  thigh.  These  abscesses  must  be  opened 
without  delay  for  the  reason  that  the  joint  may  become  involved,  the 
vessels  may  slough,  and  there  may  be  destruction  of  tissue.  There 
may  be  permanent  flexion  of  the  leg  due  to  scar  tissue. 

Before  opening  a  popliteal  abscess  the  diagnosis  must  be  confirmed. 
It  has  happened  more  than  once  that  a  popliteal  aneurysm  has  been 
mistaken  for  an  abscess  and  incised,  a  mistake  serious  indeed  for  both 
patient  and  operator. 

Acute  inflammation  of  the  bursae  must  not  be  mistaken  for  abscess. 
These  bursa?  are  found  in  the  boundaries  of  the  space,  separating  the 
tendons  from  the  protuberances  of  the  femur,  tibia,  and  fibula. 

Operation. — Either  general  or  local  anesthesia  may  be  used.  Make 
a  vertical  incision  in  the  center  of  the  space,  dividing  the  skin,  the 
superficial  fascia,  and  the  deep  fascia  successively.  With  the  grooved 
director  separate  the  fatty  tissues  filling  the  space;  keep  in  the  line  of 
the  original  incision.  The  pus  will  usually  be  located  before  the  depth 
of  the  vessels  has  been  reached.  Enlarge  the  opening  in  the  con- 
nective tissues,  irrigate,  search  for  diverticula,  insert  a  drainage-tube 
and  pack  lightly  around  the  tube  with  aseptic  gauze.     Apply  absorb- 


ISt'lllo   \<\  (|  \i      \i:m  i  SS.  337 

mi  dressings  ;m«l  extend  the  leg  <>n  a  posterior  splint.     This  extension 
must  be  maintained  until  the  healing  is  complete  to  prevent  flexion. 

PLANTAR  ABSCESS. 

The  deep  Fascia  of  the  sole  of  the  fool  is  especially  developed.  It 
extends  as  a  broad,  dense  band  from  one  end  of  the  plantar  arch  to 
the  other,  from  the  os  calcis  to  the  base  of  the  metatarsal  bones.  It 
is  abroad  hand  divided  into  three  portions:  outer,  middle,  and  inner. 
The  central  portion  alone  is  of  much  surgical  importance.  Its  ante- 
rior extremity  is  broken  up  into  Eve  slips,  and  each  slip  branches  and 
forms  an  arch  for  a  Ilexor  tendon. 

The  result  of  this  arrangement  is  that  here  is  a  closed  compartment 
between  the  fascia  and  the  bones  of  the  foot  which  is  occupied  by  the 
muscles  of  the  middle  foot.  Following  an  infection,  pus  forming  in 
this  compartment  finds  great  difficulty  in  escaping.  It  burrows  be- 
tween the  metatarsal  bones  and  makes  its  appearance  on  the  dor- 
sum of  the  foot,  follows  the  flexor  tendons  backward  to  the  inner 
ankle,  or  may  escape  through  the  small  aperture  for  the  arteries  into 
the  subcutaneous  fascia. 

On  account  of  the  denseness  of  the  fascia,  the  pain  in  plantar  ab- 
scess is  extreme,  and  for  relief  of  this  pain  and  to  prevent  destruction 
of  tissue,  an  early  incision  is  imperative.  The  incision  should  be  made 
over  the  most  prominent  part  of  the  swelling,  its  direction  correspond- 
\  ing  to  the  long  axis  of  the  foot. 

The  skin  is  divided  and  then  the  thick  fatty  tissues,  until  the  white 
and  firm  plantar  fascia  is  reached.  After  the  fascia  is  divided,  the 
dissection  is  completed  with  a  grooved  director  until  the  pus  cavity 
is  located.  In  this  manner  no  important  structures  are  wounded. 
Wash  out  the  cavity  and  insert  a  small  drainage-tube.  It  is  important 
that  the  cavity  heal  from  the  bottom. 

ISCHIO-RECTAL  ABSCESS. 

The  ischio-rectal  fossa  is  a  wedge  shaped  cavity,  lying  on  either 
side  of  the  rectum,  between  it  and  the  pelvic  wall.  Its  base  is  covered 
by  the  integument  and  its  sharp  edge  is  directed  upward  and  corre- 


33* 


ABSCESS. 


sponds  to  a  line  drawn  from  the  pubes  backward  to  the  spine  of  the 
ischium — the  line  of  attachment  of  the  levator  ani  muscle,  the  "white 
line"  of  the  pelvic  fascia.  The  levator  ani  muscle  forms  its  inner 
boundary.  The  obturator  fascia  covering  the  bony  pelvic  wall  forms 
its  outer  boundary. 

The  fossa  is  filled  with  fatty  tissue  which  seems  to  form  a  packing 
and  support  for  the  rectum,  but  which  at  the  same  time  forms  a  site 
of  "lowered  resistance"  to  infective  agents. 

These  infective  agents  gain  access  to  the  fatty  tissues  of  the  fossa 
through  ulcerations  or  abrasions  of  the  rectal  mucous  membrane  or 
from  similar  conditions  in  the  integument  around  the  anal  orifice. 
For  the  most  part  the  bacteria  follow  the  lymphatics  which  have  their 
origin  in  these  localities  and  which  follow  the  branches  of  the  inferior 
hemorrhoidal  vessels  through  the  fossa.  The  abscess  may  be  second- 
ary to  prostatic  abscess. 

The  symptoms  of  acute  abscess  here  are  the  ordinary  constitutional 
symptoms  in  marked  degree,  accompanied  by  intense  throbbing  pain 
in  the  region  of  the  anus.  The  skin  becomes  brawny  and  indurated 
but  no  fluctation  appears  in  many  cases. 

The  symptoms  of  chronic  abscess  differ  only  in  degree,  and  are 
often  so  slight  as  to  be  entirely  overlooked.  Abscess  of  any  kind  in 
this  locality,  when  diagnosed,  should  be  evacuated  without  delay.  If 
let  alone  it  will  eventually  open  into  the  rectum  or  through  the  skin 
if  the  patient  shoul  survived  the  general  sepsis.  But  spontaneous 
evacuation  is  in  every  way  to  be  avoided,  if  possible.  A  fistula  is  the 
inevitable  sequel  if  the  case  is  left  to  nature. 

This  fistula,  opening  into  the  bowel  whether  the  abscess  formed 
near  the  roof  of  the  fossa  or  near  the  floor,  is  very  likely  to  be  just  above 
the  external  sphincter.  There  the  bowel  wall  is  thinnest,  and  the 
fascias  of  the  levator  ani  act  as  an  inclined  plane  along  which  the  pus 
moves  toward  that  part  of  the  bowel. 

The  examining  finger  in  the  rectum  in  the  case  of  abscess  will 
nearly  always  detect  the  threatened  opening  there  and  confirm  the 
diagnosis. 

Operation. — General  anesthesia;  lithotomy  position;  antisepsis. 

The  incision  (Fig.  255),  four  or  five  inches  in  length,  is  made  from 


I'l   R]    R1  (    I  M.     ABSCESS. 


before  backward  and  inclined  a  little  outward  midway  I  etween  the 
ischial  tuberosity  and  the  rectum.  Remember  that  cutting  too 
near  the  middle  line,  you  may  wound  the  rectum;  too  near  the  pelvi< 
wall,  you  may  wound  the  internal  pudic  vessels.  Some  small  hemor- 
rhage will  follow  the  skin  incision.  It  may  be  necessary  to  cut  deeper 
along  the  same  line  and  you  may  wound  some  of  the  branches  of  the 
inferior  hemorrhoidal  arteries,  but  that  is  not  a  serious  matter. 

\\  ith  a  little  patience,  in  this  manner  the  pus  is  reached  and  it  [tours 
out,  extremely  fetid  and  often  mixed  with  shreds  of  connective  tissue. 

Enlarge  the  wound  so  that  it  may  be  inspected  and  explore  it  with 


FiG.'asS- — Ischio-rec 


Incision.     (Veau.)  \ 


the  finger.  Irrigate  vigorously.  Being  assured  that  all  the  minor 
cavities  are  opened  up,  introduce  a  large  drainage-tube  and  pack 
around  it  with  gauze.  The  dressing  must  be  renewed  daily  at  first. 
The  tubes  can  be  gradually  withdrawn. 

It  is  absolutely  necessary  that  the  wound  heal  by  granulation  from 
the  bottom  and  this  may  be  a  matter  of  weeks  or  even  months.  Of 
this  the  patient  should  always  be  forewarned.  During  this  time  the 
dressings  must  be  carried  out  methodic  ally.  Often  following  incision 
and  drainage  there  is  a  tendency  to  relapse  because  the  primary  focus 
of  suppuration  in  the  prostate  has  not  been  recognized  and  relieved. 

If  a  small  opening  is  exposed  high  up  in  the  cavity,  through  which 
pus  drains,  it  indicates  a  perirectal  abscess  above  the  levator  ani, 
dangerous  because  it  may  become  a  general  pelvic  cellulitis  or  peritoni- 


34-0  ABSCESS. 

tis.  Enlarge  the  opening  by  the  introduction  of  a  dressing  forceps, 
irrigate  and  drain. 

These  peri-rectal  abscesses  not  involving  the  ischio-rectal  fossa  are 
difficult  to  diagnosticate,  but  when  once  determined  they  must  be 
opened  in  the  manner  already  indicated. 

Again,  the  ischio-rectal  abscess  may  have,  unfortunately,  already 
opened  through  the  rectal  wall.  Make  the  skin  incision  as  before,  and 
then  an  additional  step  is  necessary.  Push  a  grooved  director  up 
through  the  abscess  cavity  and  through  the  rectal  opening  and  then, 
following  along  the  grooved  director,  cut  through  the  entire  thickness 
of  the  rectal  and  anal  walls,  holding  one  finger  in  the  rectum  to  guide 
the  knife.  It  will  look  like  a  very  long  wound,  and  yet  it  has  the  excel- 
lence of  favoring  recovery  and  of  preventing  a  fistula.  However, 
under  the  most  favorable  circumstances,  it  may  require  several  months 
to  heal  (Lejars). 

PERI-ANAL  ABSCESS. 

These  are  much  less  serious  than  those  of  the  ischio-rectal  region, 
both  with  regard  to  prognosis  and  treatment.  However,  if  neglected, 
they  are  likely  to  result  in  a  fistula;  even  if  not  properly  incised  they 


Fig."256. — Incision  for  peri-anal  abscess.      {Veau.) 

may  so  result.  The  peri-anal  abscess  is  in  the  glands  surrounding 
the  anal  margin  and  lies  under  the  integument  or  mucous  membrane. 
Local  anesthesia  is  all  that  is  necessary  except  for  those  who  are  timid, 
and  with  them  general  anesthesia  is  indispensable. 


PROSTATIC   ABS4  I  34I 

Puncture  the  tumor  at  its  apex.  The  pus  is  foul  smelling.  Irrigate; 
explore  the  cavity  methodically  with  a  grooved  director.     There  is 

nearly  always  an  ascending  diverticulum  on  the  anal  side  which  com- 
municates with  the  rectum.  Having  located  the  apex  of  the  cavity, 
push  the  point  of  the  director  through  the  mucous  membrane;  in  other 
words,  make  a  fistula  if  one  does  not  already  exist  (Fig.  256).  Divide 
all  the  tissues  over  the  director,  in  this  manner  laying  open  the  cavity 
and  anal  margin.  Carefully  wipe  out  the  walls  of  the  abscess  and 
pack  with  iodoform  gauze.  As  important  as  the  operation  is  the  after- 
treatment.  This  the  doctor  must  attend  to  himself.  The  dressing 
must  be  made  daily,  washing  and  packing  lightly.  After  each  move- 
ment of  the  bowels,  the  wound  must  be  washed  and  the  packing  re- 
placed, if  possible.  It  is  essential  that  the  cavity  granulate  from  the 
bottom.     Repress  excessive  granulation  with  tincture  iodine. 

PROSTATIC  ABSCESS. 

The  prostate  gland,  about  the  size  and  shape  of  a  chestnut,  lies 
at  the  base  of  the  bladder,  clasping  but  not  quite  encircling  the  first 
portion  of  the  urethra.  The  upper  surface  of  the  urethra  is  covered 
by  fibrous  tissues  which  connect  the  upper  surface  of  the  two  lateral 
halves  of  the  prostate,  so  that  the  urethra  apparently  makes  a  tunnel 
through  the  prostate.  The  ejaculatory  ducts  empty  into  this  portion 
of  the  urethra. 

The  prostate  is  in  contact  with  the  second  portion  of  the  rectum 
one  and  one-half  to  two  inches  from  the  anal  orifice.  The  apex  rests 
against  the  triangular  ligament,  which  separates  it  from  the  bulb  of  the 
urethra. 

Suppurative  inflammation  in  the  prostate  originates  from  infection 
caught  up  by  the  lymphatics  of  the  prostatic  and  membranous 
portions  of  the  urethra.  These  infective  agents  arc  the  gonococci, 
staphylococci,  streptococci,  bacilli  coli  communis. 

As  might  be  expected,  gonorrhea  is  the  most  frequent  cause,  both 
lirectly  and  indirectly.     The  passage  of  sounds,  perineal  bruises,  sex- 
ual excesses,  and  high  living  in  one  way  <>r  another  favor  the  develop- 
ment   of    an    inflammatory    process    which    may    result    in   abscess 
formation. 


342  ABSCESS. 

The  abscess  may  be  limited  to  the  gland  substance  or  may  develop 
in  the  connective  tissue  surrounding  the  gland.  In  this  case  it  may 
be  called  a  pelvic  abscess.     It  may  become  an  ischio-rectal  abscess. 

Chronic  prostatic  abscess  may  be  overlooked  and  unrecognized  as 
the  direct  cause  of  many  conditions:  chronic  urethral  discharge; 
vesical  and  rectal  irritation;  rectal  fistula;  chronic  inflammation  of  the 
prostatic  adnexa  (the  ejaculatory  ducts  and  seminal  vesicles);  sup- 
purating epididymitis  and  orchitis;  nocturnal  emissions. 

Any  abscess  of  the  prostate  may  open  into  the  rectum,  bladder, 
urethra,  perineum,  or  suprapubic  region.  Finally  there  is,  in  the  case 
of  acute  abscess,  the  imminent  danger  of  the  general  involvement  of 
the  pelvic  fascia,  ending  in  septicemia.  It  is  manifest  that  a  prostatic 
abscess  is  a  constant  menace.  Its  evacuation  must  not  be  delayed. 
It  cannot  be  denied  that  oftentimes  spontaneous  evacuation  is  followed 
by  a  complete  cure,  but  the  outlook  is  many  times  more  favorable  with 
immediate  operation.  Sometimes  the  only  cure  is  in  complete  re- 
moval of  the  gland. 

Diagnosis. — There  is  usually  a  history  of  gonorrhea,  recent  or  re- 
mote. Fever  and  a  few  chills;  violent  perineal  pain,  radiating  to  the. 
rectum  and  thighs;  painful  and  difficult  urination  and  defecation 
point  to  probable  suppuration  in  the  prostatic  region.  A  little  later 
perhaps  the  perineum  is  reddened,  swollen,  and  infiltrated.  Complete 
the  diagnosis  by  introducing  a  well-oiled  finger  into  the  rectum,  which 
will  excite  much  pain.  On  the  anterior  wall  of  the  rectum  will  be 
found  a  large  unsymmetrical  swelling,  more  or  less  clearly  fluctuating, 
and  which  loses  itself  in  a  doughy  tumor  extending  toward  the  sides 
of  the  rectum  and  the  anus.  Now  must  one  operate  even  though  there 
be  some  pus  discharging  through  the  urethra,  having  begun  spon- 
taneously or  following  the  passage  of  a  catheter.  Such  drainage  is 
quite  insufficient. 

There  are  two  methods  of  operation:  (a)  the  rectal  route  when 
the  abscess  is  about  to  burst  into  the  rectum;  (b)  the  perineal  route, 
under  all  other  conditions.  In  either  condition  general  anesthesia  is 
indispensable.  The  perineum  and  its  vicinity  are  carefully  sterilized 
and  the  patient  placed  in  the  lithotomy  position  for  the  perineal  in- 
cision. 


PROSTA'l  !«■     M'.SCI  SS. 


343 


Rectal  route:  Place  the  patienl  on  the  righl  side,  flex  the  left  thigh 

ft)  the  abdomen  and  let  the  assistant  hold  up  the  left  buttock.  Dilate 
the  anus  and  give  the  rectal  mucosa  a  thorough  lavage,  washing  with 
fcap  and  water  and  gauze,  followed  by  an  alkaline  antiseptic  solution. 
Retract  the  posterior  wall  of  the  rectum  with  a  Sims'  speculum. 
The  anterior  wall  will  thus  he  exposed  to  inspection.  Locate  by 
touch  the  thinnest  part  of  the  abscess  wall,  for  the  tumor  will  not  be  so 
conspicuous  to  sight  as  it  is  to  the  touch.  Without  hesitation  push 
the  point  of  the  knife  one-half  inch  into  the  tumor.     This  is  to  be  done 


Fig.  257. — Prostatic  abscess:  patient  in  lithotomy  position;  incision  between  bulb 
and  anus  extending  laterally  to  the  ischial  tuberosities.     {Veau  after  1'icrrc  Duval.) 

by  sight  and  not  by  touch.  When  the  pus  flows,  enlarge  the  opening, 
cutting  toward  the  anus.  Make  the  opening  at  leastan  inch  in  length. 
Favor  the  flow  by  slight  pressure,  and  finally  irrigate.  You  may  be 
satisfied  with  that,  leaving  no  drainage,  but  repeating  the  rectal  Hush- 
ing several  times  daily  at  first.  If  the  cavity  is  deep  and  if  there  is 
considerable  oozing,  it  is  better  to  pack  very  lightly  with  aseptic  gauze, 
which  will  be  expelled  with  the  first  movement  of  the  bowels. 

Perineal  route:  An  incision  one  inch  in  front  of  the  anus,  transverse, 
[lightly  curved  with  convexity  forward  (big.  257).  This  incision  di- 
vides the  skin  and  superficial  fascia-    edematous,  it  may  be.     Separate 


344 


ABSCESS. 


the  edges,  of  the  wound  and  identify,  if  possible,  the  muscular  layers 
composed  of  the  transversus  perinei,  the  sphincter  ani  and  accelerator 
urinae,  which,  coming  from  the  cardinal  points,  meet  at  the  "central 
tendinous  point  of  the  perineum,"  which  is  to  be  next  incised.  If 
these  structures  are  not  recognizable,  the  bulb  of  the  urethra  covered 
by  the  accelerator  urinae  can  at  least  be  found.  It  is  a  prominence 
which  the  finger  if  not  the  eye  will  readily  detect.     Incise  transversely 


Fig.  258. — Prostatic  abscess.  Showing  relation  of  structures  concerned  in  opera- 
tion; in  front  the  bulb  of  the  urethra,  on  either  side  the  erectors  of  the  penis,  trans- 
versely the  transversus  perinei  which  is  divided  parallel  with  its  fibers.  (Veau 
after  Pierre  Duval.) 

through  the  middle  of  the  transverse  perinei  (Fig.  258),  or  at  least  just 
behind  the  bulb.  The  transversus  perinei  artery  will  be  divided. 
Now  draw  the  bulb  forward  out  of  the  way  with  a  retractor  and  pull 
the  posterior  lip  backward  with  an  artery  forceps. 

Make  the  third  transverse  incision  through  the  layer  now  well  ex- 
posed, viz.:  the  superficial  layer  of  the  triangular  ligament,  a  dense, 
fibrous  membrane.  The  abscess  is  now  covered  only  by  the  deep 
layer  of  the  triangular  ligament,  and  this  is  best  opened  up  with  the 
grooved  director,  working  forward  in  order  to  avoid  the  rectum,  which 
ies  immediately  behind  (Fig.  259). 


PROSTATIC    VBS< 


.VI 5 


As  soon  as  the  cavity  is  Located,  enlarge  the  opening  with  the  for<  eps, 
irrigate  gently,  place  a  drainage  tube  and  use  an  absorbent  dressing, 
which  is  to  be  removed  cai  h  morning  and  evening  and  after  stool. 

Irrigation  and  Drainage  of  the  Seminal  Duct  and  Vesicle. — Purulent 
accumulations  in  the  seminal  vesicles  demand  relief  on  account  oi  the 
frequent  urination  and  other  symptoms  which  sometimes  may  be  at- 
tributed to  the  prostate  itself. 

Belfield,  of  Rush  Medical  College,  accomplishes  the  relief  of  these 
conditions  by  drainage  through  the  vas  deferens. 


PlG.    .'5'i.      Prostatic  abscess;  showing  relation   to  bladder  and   rectum  and   the 
muscular  and  fibrous  layers  to  be  divided.      (Veau.) 

The  vas  deferens  is  caught  between  the  lingers  at  the  base  of  the 
S(  rotum  and  brought  up  against  the  skin  and  held  by  a  half-curved 
needle  passed  through  the  skin  under  the  vas.  A  half-inch  incision 
under  local  anesthesia  is  then  made  over  the  vas;  it  is  exposed  and 
opened  by  a  longitudinal  or  transverse  incision.  The  blunted  needle 
of  a  hypodermic  syringe  is  then  passed  into  the  canal  and  the  solution 
injected.  The  liquid  traverses  the  \as  and  the  ampulla,  and  distends 
the  seminal  yesi<  les. 

If  necessary  the  vas  may  be  stitched  to  the  skin  by  a  line  silkworm 


346  ABSCESS. 

gut  suture,  and  a  fistula  thus  established,  through  which  daily  in- 
jections may  be  made.  By  this  means,  too,  the  vas  is  made  to  serve 
as  a  drainage-tube  for  the  ampulla. 

A  fine  silkworm-gut  may  be  passed  into  the  canal  and  left  until  the 
next  injection.  Belfield  recommends  the  procedure  for  chronic  gon- 
orrheal infections  of  the  seminal  canal;  chronic  pus  infections  in  the 
elderly  (often  mistaken  for  enlarged  prostate);  for  acute  gonorrheal 
spermato-cystitis;  and  for  the  abortion  of  threatened  epididymitis. 

VULVAR  ABSCESS. 

The  labia  majora  are  composed  of  areolar  and  fatty  tissues,  bounded 
on  one  side  by  skin  and  on  the  other  by  mucous  membrane. 
These  integuments  have  many  sebaceous  follicles  and  are  exposed  to 
various  forms  of  infection  and  traumatism.  Along  these  sebaceous 
follicles  and  the  lymphatics,  agents  of  suppuration  may  travel  to  reach 
the  areolar  tissues,  which  are  so  prone  to  yield  to  the  attack. 

The  traumatisms  of  accident  and  brutality  and  excessive  coitus 
then  are  the  predisposing  causes;  the  streptococci  and  gonococci, 
the  specific  agents  of  inflammation  of  the  vulva,  which  may  end  in 
abscess.  The  suppuration  takes  on  the  diffuse  rather  than  the  cir- 
cumscribed form.  The  labium  majus  of  the  affected  side  is  swollen, 
doughy,  reddened,  dry,  and  there  are  the  other  local  and  constitutional 
signs  of  suppuration.  The  skin,  apparently  more  than  the  mucous 
membrane,  is  involved  and  the  lesser  labium,  scarcely  at  all.  In  order 
to  avoid  general  infection,  or  an  ugly  slough  from  spontaneous  evacua- 
tion, the  abscess  must  be  incised  immediately.  The  presence  of  pus 
can  nearly  always  be  determined  by  fluctuation.  After  careful  anti- 
septic preparation,  a  vertical  incision  in  the  site  of  the  greatest  swelling, 
usually  in  the  integument,  will  be  sufficient.  There  are  no  vessels 
to  fear.  Ordinarily,  a  strip  of  iodoform  gauze  will  furnish  sufficient 
drainage.     An  absorbent  dressing  and  rest  will  soon  bring  about  a  cure. 

VULVO-VAGINAL  ABSCESS.     (ABSCESS  OF  BAR- 
THOLIN'S GLAND.) 

Beneath  the  vaginal  mucous  membrane,  near  the  junction  of  the 
lateral  and  posterior  walls,  between  the  lesser  labium  in  front  and  the 


Vl'l  VI)   \  M.IWI.    AHSCKSS. 


347 


liangular  ligament  behind,  is  Bartholin's  gland,  one  on  cadi  side.  The 
■and  is  normally  about  the  size  of  a  small  almond,  and  is  about  oneor 
,,,<•  and  one  half  inches  from  the  vulvar  orifice.  Its  duct  opens  into  the 
Elvar  canal  just  external  to  the  hymen  or  its  remains,  the  carunculae 

myrtiformes.     Its  lymphatics  empty  into  the  superficial  glands. 

Its  relation  of  greatest  surgical  importance  is  with  the  venous  plexus 

(the  bulb  of  the  vagina),  which 

covers  its  upper  half  and  which 

may   he    wounded    by   too   free 

incision.      As    in    the    case    of 

vulvar  abscess,  the  cause  of  sup- 
puration is  an   infective  agent, 

most  frequently  the  gonococcus, 

which  reaches  the  gland  by  way 

of  the  excretory  duct.    Excessive 

coitus   is  a  predisposing   cause. 

The  symptoms  at  first  are  those 

of    acute   inflammation   of    the 

vulva    or    vagina;     finally    the 
symptoms  become  localized. 

On  examination  the  vaginal 
orifice  is  found  to  be  almost 
closed  on  account  of  the  swell- 
ing, and  the  mucous  membranes 
hot  and  dry.  The  examining 
finger  detects  on  the  affected 
side  a  well-defined  body  vary- 
ing in  size,   perhaps  no  larger 

than  a  chestnut,  perhaps  as  large  as  a  hen's  egg.  It  is  clearly  circum- 
scribed. The  labium  ma  jus  is  only  slightly  edematous  ordinarily,  the 
lower  part  more  so.  The  abscess  must  be  incised  as  soon  as  fluctua- 
tion is  present  in  the  slightest  degree.  Several  serious  consequences 
may  attend  delay.  The  inflammation  may  follow  the  vaginal  areolar 
tissues  into  the  pelvis;  there  may  develop  a  phlebitis,  or  sloughing  of 
the  veins,  or  lymphangitis,  or.  what  is  more  common,  there  may  result 
a  recto-vaginal  fistula. 


Fig. 


260. — Vulvovaginal  abscess. 
Direction  of  incision. 


348  ABSCESS. 

Operation. — Cleanse  the  parts  carefully  under  local  or  general  an- 
esthesia, incise  the  tumor  in  the  direction  of  the  long  axis  of  the  vagina 
from  within  outward  (Fig.  260).  Incise  thoroughly,  as  this  is  the 
means  of  securing  the  drainage  that  will  prevent  a  fistula.  The  in- 
cision must  not  be  deep  near  the  vaginal  orifice  for  fear  of  wounding 
the  bulb  of  the  vestibule.  A  strip  of  gauze  will  favor  healing  from 
the  bottom  of  the  abscess.     The  region  should  be  frequently  douched. 

PELVIC  ABSCESS. 

Separating  the  pelvic  peritoneum  from  the  organs  of  this  region 
are  loose  areolar  tissues  which  are  prone  to  suppurate  when  attacked 
by  infective  agents. 

Pelvic  cellulitis  usually  begins  as  a  lymphangitis,  following  the  ab- 
sorption of  bacteria  from  some  pelvic  focus,  usually  the  Fallopian  tubes. 
A  salpingitis  is  the  most  frequent  cause  of  pelvic  abscess.  The  ar- 
rangement of  the  fascia  and  organs  is  such  that  the  inflammatory 
exudates  gravitate  to  the  cul-de-sac  of  Douglas. 

Left  to  its  own  course,  the  abscess  may  open  into  the  vagina,  rec- 
tum, or  bladder;  less  frequently  through  the  abdominal  wall,  saphen- 
ous opening,  pelvic  floor,  obturator  foramen,  sacro-sciatic  foramen,  or 
into  the  peritoneal  cavity. 

Diagnosis. — The  history  usually  given  points  to  an  attack  of  pelvic 
cellulitis,  following  an  abortion  or  complicated  confinement,  or  some 
pelvic  or  abdominal  traumatism.  The  temperature  remains  about 
ioo°  with  exacerbations  reaching  1030  or  1040.  There  are  all  the 
symptoms  of  septic  aborption. 

On  pelvic  examination  you  are  able  to  define  a  mass  bulging  down 
into  the  recto-uterine  pouch.  This  taken  with  the  fever  and  pain,  and 
perhaps  some  edema  of  the  vulva,  points  without  doubt  to  the  nature 
of  the  trouble.  A  colpotomy  should  be  done  as  soon  as  possible. 
The  instruments  needed  are  a  speculum,  a  vulsellum  forceps,  a  long 
artery  forceps  or  dressing  forceps,  curved  scissors,  a  scalpel,  an  irriga- 
tor, drainage-tube,  and  iodoform  gauze.  General  anesthesia  is  usu- 
ally necessary,  though  in  the  simpler  cases  local  anesthesia  will  suffice. 
Lithotomy  position;  the  thighs  held  well  apart,  the  shoulders  lowered, 
the  pelvis  slightly  elevated. 


i\i  [SION    FOB    I'l  I  \  n     Al 


349 


.1  careful  antisepsis:  shave  the  vulva  and  disinfect  the  inner  sur- 
kce  of  the  thighs,  and  the  pubic  region  as  well.  Disinfect  the  vagina, 
jfUbbing  it  with  soap  and  water  first  and  being  careful  to  rea<  h  every 
part  of  the  mucous  membrane,  using  the  finger  wrapped  with  sterile 

gauze.  Finally  irrigate  with  i  to  2000  bichloride  or  other  antiseptic 
solution.  Cover  the  outside  parts  with  sterile  towels.  Now  retract 
the  posterior  vaginal  wall  with  a  Sims'  speculum.  With  the  vulsellum 
force] >s  seize  the  posterior  lip  of  the  cervix  and  pull  the  cervix  forward 
(Fig.  261).     You  will  now  be  able  to  see  the  site  which  is  to  be  incised. 


Fir,.  261. — Incision  of  the  vaginal  mucous  membrane  for  abscess  in  the  posterior 
cul-de-sac.     (Veau.) 


'flu'  tumor  may  be  conspicuous,  the  edema  and  fluctuation  well  de- 
lined;  or  nothing  but  some  edema  may  indicate  the  presence  of  the 
deeper  seated  inflammation.  Do  not  attempt  a  mere  puncture,  how- 
ever well-defined  the  pus  cavity  may  be.  With  a  curved  scissors  or 
scalpel  incise  the  mucous  membrane  of  the  vault  of  the  vagina  one 
inch  behind  the  base  of  the  cervix.  Make  an  incision  from  side  to 
side,  but  do  not  approach  too  near  the  vaginal  walls  else  the  arteries 
there  may  be  wounded.     Fnlarge  the  wound  by  stripping  its  edges 


35° 


ABSCESS. 


back  a  little.  The  abscess  wall  is  exposed  and  with  a  little  puncture 
the  pus  will  flow.  However,  it  may  be  that  the  pus  is  higher  up  and 
separated  from  the  mucous  membrane  by  thick  and  edematous  areolar 
tissues,  and  this  must  not  be  taken  for  the  abscess.  From  it  will  flow 
a  serous  fluid  which  must  be  accepted  as  a  proof  of  pus  higher  up. 

With  the  finger  or  an  artery  forceps  follow  the  posterior  wall  of 
the  uterus  upward.  Do  not  dissect  backward.  The  rectum  is  there 
(Fig.  262).  Follow  the  posterior  wall  of  the  uterus  to  avoid  danger. 
There  is  always  some  hemorrhage,  in  nowise  dangerous.  It  may  be 
necessary  to  dissect  upward  for  an  inch;  it  will  seem  further  than  it 
really  is. 


Fig.  262. — Showing  the  uterus  pulled 
down,  preparatory  to  opening  the 
abscess  in  the^  posterior^  cul-de-sac. 
(Veau.) 


Fig.  263. — Showing  relations  of  abscess 
in  the  posterior  cul-de-sac.  Dotted  lines 
represent  drainage  tube.      (Veau.) 


When  once  the  cavity  is  opened  into,  enlarge  the  orifice  and  with  the 
finger  make  careful  search  for  a  secondary  cavity.  It  you  irrigate,  do 
not  employ  much  pressure.  Do  not  pack  the  cavity  with  gauze.  In- 
troduce a  long  drainage-tube  to  the  top  of  the  cavity.  Its  lower  end 
must  not  protrude  at  the  vulva  (Fig.  263).  Pack  the  vagina  lightly, 
changing  the  packing  every  day  without  disturbing  the  drainage-tube. 
You  may  wash  out  the  vagina,  but  do  not  use  much  force.  Replace 
the  drainage-tube  by  a  smaller  one  about  the  tenth  day  if  the  tempera- 
ture is  normal.  It  is  likely  that  it  will  be  pushed  out  spontaneously, 
and  if  it  cannot  be  reinstated  and  the  temperature  is  normal,  it  is 
certain  that  it  is  no  longer  necessary. 

In  the  matter  of  drainage  it  may  be  preferable  to  follow  the  plan  of 


ST  BPHR1  NIC   ABSC]  SS.  35  1 

Miller,  of  New  Orleans,  who  employs  both  tube  and  gauze.  A  tube 
is  introduced  and  plain  gauze  is  packed  around  it.  The  gauze  is  doI 
all  removed  until  after  five  days,  after  which  the  cavity  is  flushed 
through  the  tube.  The  tube  is  shortened  as  the  cavity  contracts,  hut 
seldom  entirely  removed  under  ten  or  fifteen  days  in  large  abscesses 
(New  Orleans  Med.  and  Surg.  Journal,  Sept.,  1906). 

Remember  that  the  original  cause  of  the  suppuration  has  not  been 
removed  and  after  the  abscess  has  healed  a  specialist  had  better  take 
the  case  in  hand. 

SUBPHRENIC  ABSCESS. 

A  localized  peritonitis  is  possible  only  in  those  localities  not  occu- 
pied by  coils  of  small  intestine.  The  region  immediately  below  the 
diaphragm  is  of  this  character,  and  it  is  practically  shut  off  from  the 
general  peritoneal  cavity  by  the  transverse  colon  and  its  meso-colon. 
This  space  is  subdivided  by  the  falciform  ligament  into  aright,  occu- 
pied by  the  liver;  and  a  left  occupied  by  the  stomach,  pancreas,  duode- 
num, and  spleen.  Guibal  describes  five  subdivisions  of  the  subphrenic 
space,  in  any  of  which  pus  may  collect  (Revue  de  Chirurgie,  April, 
1909). 

One  is  retro-peritoneal;  four  are  peritoneal.  The  retro-peritoneal 
space  contains  the  termination  of  the  esophagus,  the  posterior  border 
of  the  liver,  the  pancreas,  duodenum,  colon,  and  kidneys. 

Of  the  peritoneal  spaces  two  lie  between  the  liver  and  diaphragm 
and  may  be  the  seat  of  abscesses  following  lesions  of  the  liver,  gall- 
bladder and  ducts,  pylorus,  stomach,  and  duodenum.  The  third  or 
perisplenic  space  may  be  infected  through  the  greater  curvature  of  the 
stomach,  the  spleen  or  splenic  flexure  of  the  colon.  The  fourth  space, 
or  the  posterior  gastro-hepatic,  may  be  infected  through  the  posterior 
surface  of  the  stomach,  the  pancreas,  or  liver. 

In  effect,  subphrenic  abscess  is  a  localized  purulent  peritonitis,  and 
whatever  part  the  various  adjacent  organs  may  play  in  its  production, 
yet  the  most  frequent  cause  of  subphrenic  suppuration  is  appendicitis. 
The  pus  forming  around  the  appendix,  or  behind  the  cecum,  follows 
the  ascending  and  then  the  transverse  colon  to  reach  that  region. 


352  ABSCESS. 

Sometimes  it  is  impossible  to  determine  the  original  focus  of  inflam- 
mation. Usually,  however,  if  the  history  of  the  case  is  sufficiently  def- 
inite, one  may  arrive  at  a  conclusion.  For  example,  if  we  find  a 
patient  with  subphrenic  abscess  and  there  has  been  a  history  of  gastric 
discomfort,  vomiting  of  blood,  etc.,  one  would  decide  upon  perforating 
gastric  or  duodenal  ulcer.  If  there  has  been  a  history  of  jaundice  and 
symptoms  pointing  to  the  right  hypochondrium,  the  liver,  or  its  ducts, 
should  be  accused;  if  there  has  been  a  clear  history  of  previous  attacks 
of  appendicitis  one  need  not  be  in  doubt  as  to  the  starting-point  of  the 
condition  with  which  he  has  to  deal. 

Diagnosis. — You  will  have,  then,  usually,  a  history  of  some  visceral 
disturbance  followed  (very  quickly  in  case  of  perforation  of  the  stomach) 
by  a  chill,  fever,  malaise,  pain  in  the  upper  abdominal  pole.  The 
symptoms,  to  be  brief,  are  those  of  peritonitis  anywhere.  Suspecting 
from  these  symptoms  an  accumulation  of  pus  in  the  region  just  below 
the  diaphragm,  proceed  to  a  methodical  examination  by  means  of  in- 
spection, percussion,  and  palpation.  The  quantity  of  pus  may  be  so 
great,  or  so  near  the  front,  that  the  bulging  of  the  anterior  abdominal 
wall  may  settle  the  matter  without  further  examination.  In  obscurer 
cases  it  will  be  necessary  to  recall  the  normal  limits  of  dullness,  or 
tympany  of  the  various  organs,  in  order  to  determine  the  nature  and 
degree  of  their  displacement.  Remember,  too,  that  in  all  cases  follow- 
ing perforation  the  abscess  cavity  will  contain  gas  which  will  be  another 
source  of  confusion.  But  after  all,  in  the  typical  cases,  guided  by  the 
history,  the  symptoms  of  sepsis  and  the  local  signs,  one  can  rarely  go 
astray.  Aseptic  aspiration  may  be  restorted  to  in  the  doubtful  cases, 
and  one  need  not  hesitate  to  aspirate  several  times. 

But  previous  to  aspiration  the  patient  should  be  prepared  and 
should  be  operated  upon  immediately  if  pus  is  found.  The  X-ray  may 
be  helpful  in  diagnosis,  since  it  shows  an  abnormal  conformation  of  the 
diaphragm,  and  that  it  is  immobile  on  the  affected  side. 

The  great  majority  of  sufferers  from  this  condition  not  operated 
upon  die  from  sepsis.  A  general  peritonitis  may  supervene.  Left 
to  itself,  the  pus  may  open  into  the  alimentary  tract,  which  is  to  be 
regarded  as  a  complication  rather  than  a  cure,  for  such  cases  usually 
terminate  fatally  from  slowly  increasing  sepsis.      In  rare  instances 


DIAGNOSIS   <>l-    SUBPHRENIC    VBSCESS.  ;;; 

it  may  open  through  the  abdominal  wall.  Most  often,  however,  it 
extends  toward  the  thorax,  opening  through  the  diaphragm  into  the 
lung  to  In-  coughed  up.  Oftentimes  the  imminence  of  rupture  into  a 
bronchus  may  l>e  predicated  from  increased  pain  in  the  shoulder  of 
the  affected  side,  increased  cough  and  muco-purulent  or  sanguineous 
expectoration,  and  heightened  temperature.  The  pleurisy  nearly 
always  present  may  be  fibrous,  serous,  or  purulent.  An  empyema, 
so  originating,  may  even  mask  the  primary  condition.  But  whether 
the  pus  opens  into  a  bronchus,  or  the  digestive  tube,  or  through  the 
abdominal  wall,  the  result  of  nature's  drainage  is  too  doubtful.  It  is 
imperative  to  operate  as  soon  as  a  diagnosis  is  made,  for  even  a  latent 
case  may  fire  up  suddenly  and  march  to  rapid  death.  The  prognosis, 
in  fact,  does  not  depend  more  upon  the  character  and  skillfulness  of 
the  operation  than  upon  its  timeliness. 

Operation. — The  method  of  operation  depends  upon  the  location  of 
the  pus;  it  may  be  (A)  near  the  anterior  abdominal  wall,  or  (B)  it 
may  be  inaccessible  from  the  front. 

(A)  If  the  epigastric  region  is  bulging,  the  incision  should  be  over 
its  greatest  prominence  or  where  the  abscess  seems  to  point.  Redness 
and  edema  of  the  skin  should  be  taken  as  an  indication  that  the  pus 
is  well  walled  off  and  that  there  is  no  danger  of  the  incision  opening 
into  the  general  peritoneal  cavity,  which  is  an  accident  always  to  be 
guarded  against.  One  may  cut  directly  through  these  tissues  whether 
it  be  in  the  linea  alba  or  the  line  of  either  border  of  the  rectus. 

Once  the  cavity  is  opened  and  emptied,  it  is  to  be  carefully  wiped 
out,  for  there  are  usually  collections  in  its  deeper  parts;  and  before 
drainage  is  inserted  it  should  be  cautiously  irrigated  with  normal  salt 
solution  or  peroxide  of  hydrogen.  Moynihan  recommends  the 
"cigarette  drain"  which  may  be  well  saturated  with  boracic  acid.  A 
counter-opening  in  the  loin  may  be  required  for  efficient  drainage. 
The  cavity  must  (ill  in  by  granulation  which  may  require  six  or  eight 
weeks. 

(B)  i.  If  the  abscess  is  behind  the  liver  on  the  right  side,  an  inci- 
sion along  the  costal  margin  is  perhaps  the  best.  Divide  the  muscles, 
or  even  resect  the  twelfth  rib,  and  then,  by  blunt  dissection,  follow  the 
under  surface  of  the  diaphragm  until  the  abscess  cavity  is  reached. 

23 


354 


ABSCESS. 


If  the  abscess  is  retro-peritoneal  it  may  be  necessary  to  expose  the  upper 
pole  of  the  kidney  and  to  draw  it  downward  and  forward,  exposing  the 
renal  fossa  on  the  under  surface  of  the  liver,  and  thence  work  upward 
between  the  posterior  margin  of  the  liver  and  the  diaphragm.  Insert 
drainage-tubes  packed  about  with  iodoform  gauze. 

2.  More  often  it  is  best  to  employ  the  transpleural  route  (Fig.  264), 
which  will  require  resection  of  a  rib  or  perhaps  more  than  one.  The 
incision  exposes  the  eighth  or  ninth  rib — right  side;  eighth  or  seventh — 
left   side.     (For   technic    of   resection  of    rib,  see  page  441.)     The 


Fig.  264. — Subphrenic  abscess.     Opening  in  the  mid-axillary  line.    {Bryant.) 

center  of  the  incision  lies  in  the  axillary  line  and  about  three  and  one- 
half  inches  of  rib  are  to  be  removed. 

Now  determine  the  condition  of  the  pleura  of  which  the  cul-de-sac 
is  exposed.  In  this  region  the  pleura  is  easily  stripped  away  from  the 
chest  wall,  and  so  room  may  be  made  to  open  the  diaphragm  without 
opening  the  pleural  cavity.  If  this  can  be  done,  evacuate  and  drain 
the  abscess  as  described  above. 

Ordinarily  it  will  be  necessary  to  open  the  pleural  cavity,  which  is 
first  to  be  aspirated  if  it  contains  serum;  or  opened  and  wiped  out  if  it 
contains  pus.  If  it  is  not  purulent  it  is  likely  to  become  so  unless  steps 
are  taken  to  prevent  its  infection  by  suturing  the  diaphragm  to  the 
upper  lip  of  the  opening  in  the  chest  wall. 

You  are  now  ready  to  open  the  diaphragm  and  the  pus  cavity.     In 


PSOAS  ABSCESS.  355 

pome  rases  a  perforation  will  be  found  in  the  diaphragm,  and  this  is 
to  be  merely  enlarged;  or,  it'  inconvenient  for  drainage,  may  he  disre- 
garded and  the  incision  made  lower  down.      Drain. 

A  single  case  will  exemplify  some  of  the  characters  and  progn 
the  disease.  A  farmer,  thirty  years  of  age,  had  suffered  for  several 
years  with  a  severe  affection  of  the  stomach,  of  which  no  definite  diag- 
nosis had  been  made.  Though  debilitated,  he  was  yet  able  to  do  his 
work  about  the  farm.  Without  warning  he  was  suddenly  seize  with 
a  violent  hematemesis. 

The  attack  continued  for  some  hours  without  relief  and  the  total 
amount  of  blood  vomited  was  appalling.  But  gradually  the  bleeding 
ceased,  leaving  the  patient  prostrate.  A  tardy  convalescence  followed, 
interrupted  by  an  intermittent  fever  diagnosed  as  malaria.  A  month 
elapsed  and  he  was  brought  to  bed  with  a  fresh  access  of  "ague" — 
chills,  fever,  and  exhausting  sweats.  At  this  time  a  consultation  ex- 
posed the  real  character  of  the  process.  There  was  a  vast  accumu- 
lation of  pus  in  the  left  side  involving  the  abdomen  and  thorax.  A 
constant  irritating  cough,  a  bloody  sputum,  severe  pain  in  the  left 
shoulder,  and  increased  fever  and  dyspnea  seemed  to  indicate  the 
nearness  of  rupture  into  a  bronchus.  In  fact  this  occurred  within  a 
few  hours  after  our  examination.  A  large  amount  of  pus  was  coughed 
up  and  with  temporary  relief.  An  operation  was  refused.  Indeed,  it 
offered  but  little  hope  so  late  in  the  course  of  the  disease.  A  week 
later  he  died.  Had  the  perforation  of  the  gastric  ulcer  been  recog- 
nized, or  even  later  the  character  of  the  sepsis  been  understood,  an 
o] (oration  would  have  saved  his  life. 

PSOAS  ABSCESS. 

Psoas  abscess  is  a  term  sometimes  rather  loosely  applied  to  purulent 
collections  in  the  iliac  region.  Properly  speaking,  it  is  a  tubercular 
abscess  having  its  origin  in  caries  of  the  lower  cervical,  dorsal,  or 
Lumbar  vertebrae. 

It  is  necessary  to  recall  the  arrangement  of  certain  muscles  and 
fascias.  The  psoas  muscle,  a  rounded  fleshy  mass,  lying  alongside 
the  bodies  of  the  lumbar  vertebra?,  extends  across  the  pelvic  brim,  and 
passes  in  front  of  the  hip-joint  to  be  inserted  into  the  lesser  trochanter. 


356  ABSCESS. 

The  iliacus,  its  companion  muscle,  occupies  the  iliac  fossa  and  con- 
verges below  in  a  tendon  which  merges  with  that  of  the  psoas.  These 
muscles  are  covered  by  the  iliac  fascia  which  is  so  attached  as  to  make 
the  iliac  fossa  practically  a  closed  compartment. 

The  fascia  is  separated  from  the  muscles  by  a  loose  areolar  tissue 
in  which  suppuration  may  originate  and  which  constitutes  an  iliac 
abscess.  This  fascia  on  its  other  side  is  separated  from  the  perito- 
neum by  another  layer  of  connective  tissue — the  subperitoneal  areolar 
tissue,  which  is  liberally  supplied  with  fatty  tissue  and  constitutes  a 
site  of  lowered  resistance  to  germs  originating  in  the  pelvic  viscera, 
the  cecum,  the  sigmoid,  and  the  appendix.  Suppuration  under  this 
layer  usually  ends  as  a  pelvic  abscess. 

It  is  evident,  therefore,  that  an  iliac  abscess  beginning  as  such,  and  ab- 
scess in  the  subperitoneal  tissues,  are  quite  distinct  from  psoas  abscess, 
except  that  all  have  common  points  of  possible  opening.  The  iliac 
fascia  covers  the  muscles  in  the  iliac  fossa,  but  it  also  extends  upward 
in  such  manner  as  to  ensheath  the  psoas  and  separate  it  from  the 
bodies  of  the  vertebrae. 

In  the  case  of  caries,  the  products  of  decomposition  may  burst 
through  the  vertebral  ligaments  and  the  sheath,  and  thereafter  follow 
the  psoas  muscle  downward.  The  muscle  itself  may  be  decomposed 
in  whole  or  part,  and  the  accumulating  pus  may  be  directed  by  the  tubu- 
lar sheath  to  its  point  of  termination  below  Poupart's  ligament  to  the 
outer  side  of  the  iliac  vessels.  Or,  again,  the  abscess  may  burst 
through  the  sheath  higher  up  and  point  in  the  loin  (lumbar  abscess) ; 
or  may  point  just  above  Poupart's  ligament  in  the  gluteal  region,  the 
pelvis,  the  scrotum,  or  thigh. 

The  diagnosis  of  psoas  abscess  rests  upon  the  history  of  the  case, 
which  points  to  spinal  trouble,  and  upon  the  presence  of  fluctuating 
swelling  in  the  iliac  fossa,  or  below  Poupart's  ligament.  Usually  the 
hip  is  flexed  in  some  degree,  as  by  that  position  the  tension  in  the  psoas 
is  relieved. 

This  flexion  and  some  apparent  stiffness  in  the  joint  might  lead 
to  a  mistaken  diagnosis  of  hip-joint  disease.  The  swelling  is  to 
be  distinguished,  also,  from  a  hernial  tumor,  by  the  fact  that  it  is  fluc- 
tuating and  lies  at  the  outer  side  of  the  iliac  vessels. 


OPERATION    I  <>R    PSOAS   ABSCESS.  357 

Treatment-  As  in  all  cases  of  tubercular  abscess,  secondary  infec- 
tion and  amyloid  degeneration  arc  most  to  be  dreaded.  For  that 
reason,  spontaneous  rupture  and  treatment  by  small  incision  and 
prolonged  tubal  drainage  are  equally  dangerous. 

As  early  as  possible  an  aseptic  evaluation  must  be  practised.1 
this  may  be  accomplished  by  puncture  and  the  subsequent  injection  of 
iodoform  emulsion;  this  seems  the  advisable  procedure,  if  the  abscess  is 
pointing  in  the  region  of  Poupart's  ligament,  and  it  is  likely  that  the 
destructive  process  in  the  vertebra  is  in  abeyance.  In  general,  most 
authorities  recommend  the  operation  of  Treves,  by  the  lumbar  route. 

Operation. — Begin  by  locating  the  last  rib,  the  crest  of  the  ilium, 
and  the  outer  border  of  the  erector  spina?.  The  incision,  two  and 
one-half  inches  long,  with  its  center  half  way  between  these  bony  land- 
marks, follows  the  outer  border  of  the  erector  spina?  and  exposes  at 
first  the  lumbar  fascia. 

Divide  the  first  layer  of  the  lumbar  fascia  and  expose  the  erector 
spinas.  Develop  its  outer  border  the  whole  length  of  the  wound 
and  retract  the  muscle  inward,  exposing  the  middle  layer  of  the  lumbar 
fascia.     Divide  this  layer  which  exposes  the  quadratus  lumborum. 

Divide  the  quadratus  lumborum  along  the  line  of  its  attachment 
to  the  tips  of  the  transverse  processes,  which  exposes  the  deep  or  an- 
terior layer  of  the  lumbar  fascia.  Divide  this  layer  and  finally  the 
psoas  magnus  is  exposed.  Divide  the  attachment  of  the  psoas  magnus 
sufficiently  to  introduce  the  finger,  which  opens  up  the  abscess  cavity 
and  determines  the  condition  of  the  carious  vertebra. 

The  abscess  cavity  is  to  be  treated  by  thorough  irrigation  with 
an  antiseptic  solution,  wiped  vigorously,  or  even  curetted.  The 
various  layers  are  sutured  without  drainage  and  an  antiseptic  dressing 
applied. 

Previous  to  suturing,  the  cavity  may  be  filled  with  iodoform  emul- 
sion; or,  as  Walsham  suggests,  after  tin-  cavity  is  cleansed  it  may  be 
packed  with  strips  of  iodoform  gauze,  which  are  to  be  changed  on  the 
third  or  fourth  day.  If  at  the  end  of  a  week  no  pus  has  appeared 
and  the  cavity  is  lined  with  healthy  granulations,  the  wound  may  be 
closed  by  secondary  suture. 


CHAPTER  XVIII. 
PHLEGMON:  ACUTE  SPREADING  INFECTIONS. 

The  areolar  tissues  are  less  resistant  than  others.  The  streptococci 
in  their  mode  of  development  tend  to  spread  out  so  that,  under  favor- 
able circumstances,  the  streptococcic  infection  of  the  subcutaneous 
connective  tissues  becomes  one  of  the  most  dangerous  conditions, 
demanding  immediate  and  radical  surgical  intervention. 

The  rapid  development  of  toxins  makes  death  from  septicemia  to  be 
feared;  or,  short  of  this,  there  may  be  great  destruction  of  tissue  and 
subsequent  loss  of  function. 

Certain  regions,  owing  to  the  opportunities  for  infection  and  the 
arrangement  of  the  tissues,  are  more  likely  to  be  affected  than  others; 
but  the  general  symptoms  and  the  principles  of  treatment  are  the  same. 

One  peculiarity  of  this  inflammation  is  that  pus  is  often  slow  to 
form,  so  that  when  the  engorged  tissues  are  incised  in  the  earlier  stages, 
merely  a  serum  exudes.  It  is  innocent-looking,  but  it  is  toxic  in 
the  extreme. 

The  point,  then,  is  this — do  not  wait  for  pus  formation  and  fluctua- 
tion, before  evacuating  these  products.  If  pus  has  formed,  immediately 
is  none  too  soon  to  operate. 

In  the  case  of  superficial  phlegmon  of  moderate  severity,  it  will 
often  be  harmless  to  try  to  localize  the  process  by  the  use  of  hot  anti- 
septic poultices  or  baths,  but  the  safest  thing  is  free  incision  for  drainage. 

The  incision  must  reach  the  deepest  layer  of  the  affected  tissues, 
as  anything  less  is  useless;  it  may  even  be  harmful  by  introducing  a 
new  infection  to  tissues  which  were  not  previously  involved. 

Slight  injuries,  with  subsequent  localized  accumulations  of  pus, 
are  often  the  source  of  an  infection  which  attacks  the  connective  tissues, 
reaching  them  by  way  of  the  lymphatics,  and  then  what  was  a  mere 
local  and  harmless  infection  at  first,  becomes  a  very  dangerous  diffuse 
phlegmon. 

358 


PANARIS.  359 

These  minor  conditions,  therefore,  are  emergencies  from  the  point 
of  view  of  prevention.  A  few  examples  will  serve  to  emphasize  tin- 
principles  governing  their  treatment. 

PANARIS. 

This  is  an  infection  involving  the  tissues  about  the  finger-nail.  It 
may  he  limited  to  the  epidermis,  the  dermis,  the  subcutaneous  tissues, 
or  the  perisosteum,  the  last  condition  being  usually  called  a  felon. 

Panaris,  Subcpidcnnic. — The    appearance   at   first   is   almost   that 


Fir..  265. — Opening  a  purulent  phlyctena  or  "run  a  round."      (lYii/i.) 

of  a  blister,  and  all  of  the  loosened  tegument  must  be  removed.  No 
analgesia  is  necessary,  as  the  epidermis  is  non-sensitive. 

Begin  by  pricking  the  phlyctena  with  the  point  of  the  bistoury,  and 
then  trim  around  its  whole  circumference  with  pointed  scissors 
(Fig.  265). 

Carefully  observe  the  denuded  surface,  and  a  small  opening  may  be 
found,  leading  to  a  deeper  cavity  (button-hole  abscess)  which  will 
require  incision. 

Complete  the  treatment  by  a  prolonged  antiseptic  bath  and  antiseptic 
dressing. 


360  PHLEGMON:   ACUTE    SPREADING   INFECTIONS. 

Panaris,  Subungual. — In  this  form  the  pus  accumulates  under  the 
nail  and  loosens  it.  It  will  be  necessary  to  remove  the  part  of  the  nail 
lying  over  the  pus  accumulation.  A  cure  can  be  obtained  only  at  that 
price. 

If  it  is  confined  to  one  side  only,  the  skin  is  removed  as  described 
above,  the  sharp  point  of  the  scissors  introduced  under  the  nail,  and 
enough  of  it  resected  to  expose  the  suppurating  surface.  If  both 
sides  are  involved,  remove  the  nail  completely. 

Panaris,  Subcutaneous  {Felon). — Incise  as  soon  as  pus  is  suspected. 
No  harm  can  be  done  even  if  there  is  no  pus,  while  a  day's  delay  after 
pus  has  formed  may  make  a  great  difference. 


Fig.  266. — Illustrating  the  situation  of  the  pus  in  a  felon;  the  dotted  lines  represent 
the  limits  of  the  incision.      (Veau.) 

Under  local  anesthesia  (Figs.  8,  9),  make  a  longitudinal  incision 
in  the  middle  of  the  palmar  surface  where  the  pain  is  greatest 
(Fig.  266). 

Do  not  make  a  mere  puncture,  as  the  whole  pus  cavity  must  be 
exposed.  Incise  deliberately  and  let  the  first  stroke  cut  long  and  deep 
enough,  after  which  explore  the  cavity  with  a  small  probe. 

If  there  is  a  palmar  prolongation,  enlarge  the  opening,  and  if  there 
is  a  dorsal  prolongation,  which  is  quite  rare,  make  a  counter-incision 
on  the  dorsum  of  the  finger. 

Immerse  the  hand  in  an  antiseptic  or  normal  salt  solution  for  an 
hour.     A  drainage-tube  is  unnecessary,  if  the  incision  is  properly  made. 

Dress  with  moist  antiseptic  gauze  and  give  the  hand  a  hot  bath 
with  each  daily  renewal  of  the  dressing. 

After  two  to  eight  days,  or  when  suppuration  has  ceased,  employ  a 
dry  dressing.  The  dry  dressing  favors  cicatrization,  but  the  moist 
dressing  best  relieves  pain. 


PI  II  U  NT    Tl  NO  SYNOVITIS. 


361 


SUPPURATIVE  INFLAMMATION   OF  TENDON   SHEATHS. 

Every  neglected  infection  of  the  fingers  or  palm  may  become  a 
phlegmon  of  the  tendon  sheaths. 

The  great  danger  of  these  phlegmons  is  destruction  or  adhesion 
of  the  tendons,  so  that  the  finger  remains  permanently  flexed  or  ex- 
tended, unsightly,  and  more  or  less 
useless. 

A  threatened  suppuration  may 
often  be  prevented  by  a  prolonged 
immersion  in  hot  antiseptic  or 
normal  salt  solution.  This  should 
be  continued  for  an  hour  and  used 
twice  daily. 

The  Bier  treatment  is  excellent  for 
this  purpose.  This  treatment  is  to 
be  applied  after  suppuration  occurs, 
but  not  until  the  pus  is  evacuated. 
It  shortens  the  incision  required  and 
the  time  of  repair. 

As  soon  as  pus  is  suspected,  in- 
cise freely.  Recall  the  anatomy  of 
the  parts  (Fig.  267).  The  sheaths 
of  the  flexor  tendons  extend  into 
the  palm,  whence  the  necessity  of 
a  palmar  incision.  The  tendon 
sluaths  of  the  thumb  and  of  the 
little  finger  communicate  with  the 
common  tendon  sheaths  in  the 
palm,  whence  the  additional  gravity 
when  they  are  involved.  The  com- 
mon sheaths  extend  from  the  palm 

under  the  annular  ligament  above  to  the  wrist -joint,  whence  the  neces- 
sity of  incision  in  the  fort-arm.  There  is  in  this  incision  an  element 
of  danger  by  reason  of  the  median  nerve,  which  lies  on  the  middle  oi 

the  front  of  the  wrist  between  the  two  common  sheaths.      The  ulnar 


Fig.  267. — Diagram  illustrating  the 
arrangement  of  the  synovial  sheaths  in  the 
hand.  Note  that  the  sheath  of  the  tendon 
of  the  little  finger  communicates  with  the 
sheath  common  to  all  the  flexors  of  the 
fingers  in  the  wrist  and  palm.  Note  also 
that  the  sheath  of  the  flexors  of  the  thumb 
extends  into  the  wrist  beyond  the  annular 
ligament.  The  median  nerve  passes  under 
the  annular  ligament  between  these  two 
common  sheatns.     (Veau.) 


362 


PHLEGMON:      ACUTE    SPREADING   INFECTIONS. 


artery  lies  on  the  common  sheath  on  the  ulnar  side.     The  incision 
must  pass  between  the  artery  and  the  nerve. 

Phlegmons  of  the  sheaths  of  the  first,  second,  and  third  fingers  are 
not  likely  to  extend  further  than  the  middle  of  the  palm,  while,  on  the 
contrary,  phlegmons  of  the  sheaths  of  the  thumb  and  little  finger  are 
likely  to  point  above  the  wrist. 


Fig.    268. — Suppuration _of   digital 
synovial  sheath.      Incisions.      (Veau.) 


Fig.  269. — Opening  into  the  upper  part  of 
the  ulnar  synovial  sheath.      (Veau.) 


Operation  for  Phlegmon  of  the  Synovial  Sheaths  of  the  Flexor  Ten- 
dons in  the  Fingers. — A  general  anesthesia  is  usually  necessary,  for  the 
pain  is  great.  Make  an  incision  about  an  inch  long  in  the  middle  of 
the  palmar  surface  over  the  point  of  greatest  swelling.  Incise  to  the 
bone  to  be  sure  of  opening  the  tendon  sheath.  The  wound  must  be 
of  uniform  length  in  the  superficial  and  deeper  tissues  (Fig.  268). 
If  necessary,  make  a  similar  incision  over  each  of  the  phalanges  and 
in  the  palm,  but  avoid  opening  into  the  joints.     If  the  sheath  is  dis- 


I>K  \I\  At.r    ()!•     Ll.NAK    SYNOVIA!     -III    \  I  II. 


363 


tended  with  pus,  a  drainage  tube  is  easily  passed  through  from  one 
incision  to  the  other. 

When  the  pus  has  been  Located,  immerse  the  hand  in  a  hot  normal 
salt  solution  for  an  hour  and  repeat  twite  daily.  This  greatly  favors 
the  evacuation  of  pus  and  subsequent  repair. 

Employ  moist  antiseptic  dressings  at  first. 

Operation  for  Phlegmon  of  the  Ulnar  Synovial  Sheath. — Continuous 
with  the  synovial  sheath  of  the  flexor  tendon  of  the  little  finger,  the 
ulnar  synovial  sheath  is  larger  than  the  radial  and  its  suppuration  more 
serious. 

These  phlegmons  are  usually 
consecutive  to  neglected  infections 
of  the  little  finger. 

Complete  drainage  is  indispens- 
able. Begin  by  making  an  incision 
over  the  radial  border  of  the  mini- 
mal metacarpal  (Fig,  269).  Avoid 
wounding  the  palmar  arch,  which 
might  require  ligation;  but,  after  all, 
this  is  not  a  serious  accident  and 
permits  a  freer  incision. 

When  the  pus  is  reached,  enlarge 
the  incision  so  that  the  tendon  may 
be  seen  the  entire  length  of  the 
wound.  Superficially  and  deep,  the 
incision  must  be  of  the  same  length. 

Next  introduce  a  grooved  director 
into  this  incision  and  push  it  through  the  synovial  cavity  until  its 
point,  passing  under  the  annular  ligament,  can  be  felt  beneath  the 
skin  of  the  wrist.  Incise  carefully  over  this  point  until  it  is  exposed, 
keeping  to  the  inside  of  the  tendon  of  the  palmaris  longus  to  avoid 
the  median  nerve.  When  the  point  of  the  grooved  director  is  fully 
exposed,  enlarge  the  incision  to  an  inch  and  a  half. 

No  artery  of  importance  will  be  wounded.  Pass  a  drainage-tube 
through  from  one  incision  to  the  other  (Fig.  270). 

Operation  for  Phlegmon  of  the  Synovial  Sheath  on  the  Radial  Side. — 


Fir,.     270. — Drainage     of     phlegmon     of 
the  ulnar  synovial  sheath.      (V«aw.) 


364 


phlegmon:    acute  spreading  infections. 


The  palmar  incision  may  be  made  through  the  muscles  of  the  thumb 
along  the  line  of  the  metacarpal,  but  it  is  preferable  to  make  it  in 
the  commissure  between  the  thumb  and  index-finger. 

Make  an  incision  two  fingers'  breadth  in  length.  At  the  depth 
of  one  or  two  inches  you  will  find  the  pus.  Pass  a  grooved  director 
along  the  sheath  as  in  the  preceding  case.     It  emerges  beneath  the 


Fig.    271. — Drainage   of   the   radial   synovial 
sheath.      (Veau.) 


Fig.  272. — Drainage  completed. 


skin  above  the  annular  ligament.  Locate  and  expose  the  point  of  the 
director;  in  incising  keep  to  the  outside  to  avoid  the  median  nerve. 
The  radial  artery  is  in  no  danger,  as  it  is  too  far  to  the  outside  (Fig.  271). 
In  the  same  manner  as  before,  pass  a  drainage-tube.  Immerse 
the  hand  twice  daily  for  an  hour  in  hot  normal  salt  solution,  and 
employ  a  moist  antiseptic  dressing.  The  drainage-tube  will  probably 
be  unnecessary  after  the  eighth  or  tenth  day  (Fig.  272). 


<>n  RATION    I  OB    nil  I  <.\l<>\    <>l     mi     H'kl  ARM. 


365 


SUBAPONEUR*  ►TIC  PHLEGMON  OF  THE  FOREARM. 

By  direct  infection,  <>r  by  extension  of  infection  from  the  hand,  the 
areolar  tissues  beneath  tin-  fascia  of  the  forearm  may  become  the  site 
of  a  diffuse  suppurative  inflammation. 

If  neglected,  it  follows  the  connective  tissues  into  the  intermuscular 
Spaces  and  finally  all  the  soft  parts  are  more  or  less  involved.     Free 


PlG.  273. — Incising  the  forearm  for 
phlegmon.     The  grooved  director  search- 
ing for  posterior  prolongations  of  the  pus 
formation.      (Veou.) 


Fig.  274. —  Note  manner  of  fixing  tubes 
in  drainage  for  phlegmon  of  the  forearm. 

(  1    t'iIK.1 


incision  must  he  resorted  to  without  delay.  In  the  earlier  stages  no 
pus  will  he  present,  hut  a  straw-colored  serum  pours  out  along  the 
line  of  incision. 

Operation  —General  Anesthesia.  Over  the  site  of  the  greatest 
swelling,  make  a  free  incision  in  the  long  axis  of  the  member.  This 
incision  will  traverse  a  thick,  infiltrated  layer  to  reach  the  aponeurosis, 


366  phlegmon:    acute  spreading  infections. 

which  incise  carefully,  when,  in  most  cases,  the  pus  will  pour  out. 
Enlarge  the  opening  sufficiently  on  the  grooved  director. 

Irrigate  thoroughly  with  hot  normal  salt  solution  and  mop  out  with 
sterile  gauze.  With  a  grooved  director  explore  all  the  parts  of  the 
cavity  for  a  diverticulum  (Fig.  273). 

If  necessary  make  a  counter-opening.  Tie  such  of  the  larger  ves- 
sels as  are  divided  and  place  several  large  drains  (Fig.  274).  Change 
the  dressing  twice  daily,  irrigating  each  time  with  hot  normal  salt 
solution. 

About  the  eighth  day,  smaller  drains  may  replace  those  first  em-  1 
ployed  and  these  are  usually  unnecessary  after  two  weeks.     Watch  the 
temperature  closely.     If  it  rises,  there  is  a  retention  of  pus,  the  site 
is  not  sufficiently  drained,  or  there  is  a  new  infection. 

DIFFUSE  PHLEGMON  OF  THE  ARM. 

All  the  soft  parts  are  involved  and  infiltrated  with  serum.  The 
arm  is  greatly  swollen,  edematous,  and  there  are  marked  symptoms 
of  septicemia. 

General  anesthesia  is  indispensable.  The  freest  kind  of  incision, 
even  down  to  the  bone  from  above  downward,  is  essential.  Three  or 
four  such  openings  are  not  too  many. 

Irrigate  freely  with  hot  normal  salt  or  bichloride  solution.  Moist 
antiseptic  dressings  should  be  used  and  at  first  should  be  changed 
several  times  daily. 

Incision  with  the  Thermo-cautery,  Lejars. — With  the  thermo-cautery 
make  several  large  incisions  in  tfie  axis  of  the  member,  each  at  least 
four  fingers'  breadth  in  length  and  about  two  fingers'  breadth  apart 
(Fig.  275).  Under  the  skin  will  be  found  a  thick  layer,  infiltrated 
with  bloody  serum.  Cutting  through  this,  the  aponeurosis  appears, 
which  incise  and  thus  expose  the  muscles. 

On  the  inner  side  avoid  the  vessels.  If  some  of  the  large  subcutane- 
ous vessels  are  opened  and  bleed  too  freely,  tie  them.  Irrigate  and 
dress  with  sterile  gauze  saturated  with  peroxide  of  half  strength. 

Change  the  dressing  and  irrigate  two  or  three  times  daily.  Change 
to  dry  dressings  when  granulation  is  well  under  way.     Later,  skin 


SYMPTOMS   OS    rill  i  GMOM    "i     i  m     \i  <  k. 

grafting  may  be  necessary.     In  the  long  time  necessary  for  repair, 
passage  and  passive  motion  must  be  given  the  muscles. 

PHLEGMON  OI    THE  NECK. 

An  infection  in  the  floor  of  the  mouth  may  become  diffuse  and 

spread    rapidly   down    the   neck.     The  symptoms   of  sepsis   will    be 


Fir,.  275. — Incising  a  phlegmon  of  the  arm  with  the  cautery.      (1 

aggravated  in  the  extreme  and  death  may  rapidly  supervene,  either 
from  sepsis  or  asphyxia.  The  whole  neck  may  be  brawny  and  edem- 
atous, and  the  patient's  condition  is  pitiable  indeed. 


368 


phlegmon:    acute  spreading  infections. 


Lejars  recommends  the  thermo-cautery  as  offering  the  best  hope 
of  a  cure,  though  seemingly  brutal. 

Under  general  anesthesia  several  deep  vertical  incisions  are  made 
with  the  thermo-cautery  with  numerous  punctures  between  (Fig.  276). 
Do  not  go  too  deep  over  the  anterior  border  of  the  sterno-mastoid, 
for  the  great  vessels  are  there. 


Fig.  276.— Manner  of  incising  phlegmon  of  neck  with  the  cautery.     (Veau.) 

Pack  each  incision  and  puncture  with  gauze  saturated  with  peroxide 
of  hydrogen,  and  cover  the  whole  with  a  similar  dressing  and  absorbent 
cotton.  The  dressing  must  be  kept  saturated  with  the  peroxide.  In 
the  meantime  use  the  antistreptococcic  serum. 

Watson  Cheyne  also  urges  the  use  of  the  serum,  but  does  not  use  the 
thermo-cautery.  His  plan  is  to  incise  through  the  deep  fascia  in 
several  places,  enlarging  the  openings  by  blunt  dissection.  The 
wounds  are  to  be  freely  sponged  with  undiluted  carbolic  acid,  pow- 
dered with  iodoform,  and  packed  with  strips  of  iodoform  gauze. 


CHAPTER  XIX. 
ACUTE  OSTEOMYELITIS. 

This  is  an  acute  infection  of  great  gravity,  more  often  due  to  the 
staphylococcus  or  the  streptococcus;  but,  in  rare  instances,  the  pneumo- 
coccus,  bacillus  coli  communis,  or  tubercle  bacillus  may  be  the  ex- 
citing cause. 

Usually  the  germ  reaches  the  affected  site  through  the  blood  current; 
at  other  times,  leaving  a  primary  focus  which  is  perhaps  unsuspected, 
it  reaches  its  destination  by  way  of  the  lymph  channels  or  by  continuity 
of  tissue.  For  the  germ  to  gain  a  foothold,  there  must  be  a  lowered 
resistance  or  an  impaired  nutrition.  The  predisposing  causes  are 
found  in  certain  constitutional  states  and  in  traumatism. 

The  diagnosis  is  not  always  easy  in  the  beginning,  as  the  constitu- 
tional symptoms  may  be  marked  before  the  local  signs  are  quite  definite. 
Rheumatism  does  not  have  the  symptoms  of  sepsis,  though,  indeed, 
the  fever  may  be  high.     The  pain  is  usually  in  the  joint  and  usually 
in  more  than  one  joint. 

Arthritis  likewise  involves  the  joint,  although  it  is  to  be  remembered 
that  an  arthritis  may  be  secondary  to  osteomyelitis  and  overshadow 
it  clinically,  but  the  history  of  the  case  will  usually  decide  between 
arthritis  and  osteomyelitis. 

Erysipelas  may  be  thought  of  when,  after  a  little  while,  the  skin 
becomes  brawny  and  edematous,  but  in  erysipelas  the  skin  is  so  in- 
volved from  the  first. 

The  symptoms  may  seem  to  suggest  typhoid  fever  or  other  infectious 
fevers,  but  these  may  usually  be  ruled  out  by  the  absence  of  charac- 
teristic features. 

The  symptoms  of  meningitis  are  often  present,  but  by  the  time  they 
arise,  the  local  conditions  point  to  the  nature  of  the  trouble. 

The  general  symptoms  are  those  of  sepsis;  high  fever  beginning  with 
a  chill,  rapid  pulse,  foul  tongue,  profound  prostration,  and  finally 
delirium. 

24  369 


37° 


ACUTE    OSTEOMYELITIS. 


\  Locally,  the  pain  over  the  affected  area  is  extreme,  and  the  least! 
pressure  tends  to  aggravate  it.  Gradually,  as  the  inflammation 
spreads  from  the  marrow  through  the  bone  to  the  periosteum,  thej 

skin  begins  to  swell,  redden,  become 
edematous,  and  finally  shows  fluctua- 
tion. 

In  the  virulent  cases  not  operated 
upon,  the  patient  dies  within  the  first 
few  days  from  septic  infection.  In 
the  milder  cases,  even,  large  areas  of 
the  bone  necrose. 

The  treatment,  then,  must  be 
prompt.  It  is  an  emergency.  There 
is  only  one  thing  of  any  use  to  be 
done.  The  suppurating  marrow  must 
be  evacuated  and  the  medullary  canal 
freely  opened  and  cleaned  out.  Local 
applications,  poultices,  or  even  in- 
cisions through  the  periosteum  are 
illusory.  The  bone  must  be  trephined, 
its  cavity  opened  up  at  its  most  accessi- 
ble part,  and  all  the  inflamed  tissue 
scraped  away.  The  whole  extent  of 
the  canal  may  need  to  be  opened, 
irrigated,  drained,  and  treated  with 
vigorous  antisepsis. 

Mosetig-Moorhof's*  iodoform- 
plombe  or  filling  is  applicable  to  such 
cases  as  these.  It  is  prepared  as 
follows: 

Equal  parts  of  spermaceti  and 
sesamoil  are  melted  in  an  evaporating  dish,  then  filtered  into  a 
Florentine  flask  and  sterilized  in  a  water-bath;  forty  grammes  of 
finely  powdered  iodoform  (not  crystallized)  are  put  into  a  sterile 
flask,  and  sixty  grammes  of  the  hot  fat  mixture  are  added,  under 
*  Surgery,  Gynecology  and  Obstetrics,  Vol.  Ill,  No.  4. 


Fig.  277. — Exposing  the  tibial  crest, 
opening  into  the  subperiosteal  ab- 
scess.     (Veau.) 


[ODO]  OEM    PLOMBE    FOB    BONE   ABS<  I  SS. 


371 


constant   agitation.     This   agitation   must   he   continued  without  in- 
terruption, until  the  mass  solidifies.     The  flask  is  closed  with  a  sterile 
rubber  stopper.     Before  using,  the  plombe  is  to  be  heated  in  water 
hath  to  a  little  above  50°  C. 

The  bone  cavity  is  most  carefully  prepared  for  the  reception  of  the 
filling.  Everything  must  be  removed  down  to  sound  bone.  The 
laws  of  gravity  must,  of  course,  be  observed  in  filling  the  cavity.  If 
the  cavity  is  large,  it  is  advisable  to  fill  it  in  several  steps,  letting  the 


Fig.  278. — Trephining  of  the  tibia: 
making  the  orifice.     (Veau.) 


Fig.  279. — Enlarging  the  orifice  and 
exposing  the  medullary  canal.  {Veau.) 


plombe  solidify  in  one  portion,  before  any  is  poured  into  another. 
The  cavity  must  be  dry  before  the  mixture  is  poured  in.  This  may  be 
accomplished  by  sponging,  by  the  application  of  adrenalin  to  oozing 
points,  by  hot  air,  etc.  The  course  of  healing  after  iodoform  filling  is 
aseptic  as  a  rule.  Sometimes  the  temperature  rises  within  the  first  two 
or  three  days — so-called  aseptic  fever — which  yields  to  a  cathartic. 
The  disposition  of  the  sprouting  granulations  toward  the  solidified 
plombe  varies  between  complete  closure  of  the  wound  and  healing  by 
primary  intention,  and  incomplete  closure.  In  the  first  cases,  absorp- 
tion of  the  plombe  is  effected  through  the  steadily  advancing  granula- 


372 


ACUTE    OSTEOMYELITIS. 


tions  by  vital  phenomena;  in  the  second,  by  partial  displacement  and  I 
expansion. 

OSTEOMYELITIS   OF  THE   UPPER  END    OF  THE  TIBIA. 

Here  the  disease  occurs  more  frequently  and  here,  fortunately,  is 

most  easily  operated  upon. 

General  anesthesia;  special  instru- 
ments: a  mallet,  a  gouge,  a  periosteal 
elevator  or  rugine,  and  curette. 

Begin  by  elevating  the  limb  to 
empty  the  blood  vessels.  About  thei 
middle  of  the  thigh  apply  an  Esmarch 
tube.  Do  not  apply  an  Esmarch 
bandage,  beginning  at  the  toe  and 
extending  upward,  for  that  only 
spreads  infection. 

On  the  right  side,  the  incision  com- 
mences at  the  level  of  the  tuberosity 
and  extends  to  the  middle  of  the  leg, 
following  the  sharp  crest  of  the  tibia 
just  to  its  inner  side.  However  en- 
gorged the  tissues  may  be,  this  first 
incision  reaches  to  the  bone  (Fig.  277). 
Often  by  this  first  stroke,  one  opens 
into  a  pus  cavity.  Do  not  be  beguiled 
by  this  into  thinking  the  operation 
completed.  This  collection  is  to  be 
evacuated  and  drained,  of  course,  but 
there  is  another  one  in  the  central 
canal.  Extend  the  incision  to  the 
limit  of  the  loosened  periosteum.  With  the  rugine,  expose  the  anterior 
surface  of  the  bone.  A  fistulous  opening  leading  to  the  medullary 
canal  may  possibly  be  found.     In  any  event,  proceed  to  trephine. 

At  the  upper  end  of  the  incision  make  an  opening  with  the  gouge 
down  to  the  canal.  The  pus  will  be  almost  certain  to  flow,  but  it  is 
often  difficult  to  distinguish  from  the  marrow. 


—Trephining  of  the  tibia 
Tubes  in  place.      (Veau.) 


"M  EO-MYELITIS  01     i  in     i  ic.i  \. 

At  the  lower  end  of  the  Incision,  make-  another  opening  (Fig.  27.S). 
If  again  pus  appears,  ii  is  certain  that  the  lowest  limit  of  the  suppura- 
tion  has  not  been  reached  and  you  must  lengthen  the  incision.     Con 
linue  to  expose  the  canal  until  the  full  extent  of  inflammation  has  been 

exposed.  It  may  require  the  removal  of  the  whole  anterior  surface 
of  the  tibia,  hut  you  are  engaged  in  saving  life,  so  that  hone  is  a  minor 
consideration.  Chisel  away,  then,  all  the  anterior  wall  between  the 
two  limits  of  suppuration  (Fig.  279).  Curette  vigorously  the  medul 
lary  canal  down  to  firm  and  uninllamed  hone,  and  especially  (  urette 
the  upper  part,  for  there  the  suppuration  is  greatest. 

In  the  case  of  a  child,  the  epiphyseal  cartilage  is  quickly  reached, 
and  this  one  should  try  to  avoid,  since  too  free  removal  will  end  linear 
growth. 

Next  irrigate  with  normal  salt  solution,  mop  out  thoroughly  with 
sterile  gauze,  and  pack  with  sterile  or  iodoform  gauze.  This  is  an 
important  part  of  the  operation  and  it  must  be  carried  out  thoroughly 
and  methodically. 

Drainage  must  now  be  applied  to  the  subperiosteal  areas  of  suppura- 
tion, using  rubber  drains  in  the  manner  indicated  (Fig.  280). 

If  the  operation  has  been  delayed,  the  muscles  of  the  tail" 
may  be  infiltrated  with  pus  and  will  require  drainage  as  in  diffuse 
phlegmon. 

If  there  is  serous  effusion  into  the  joint,  it  will  require  no  especial 
treatment,  for  it  will  gradually  be  absorbed  as  the  osteomyetitis  is 
cured. 

If  the  joint  is  suppurating,  it  is  quite  different  and  another  operation 
is  required  (see  operation  for  Purulent  Arthritis). 

Over  the  trephined  area,  apply  a  moist  dressing  and  change  daily. 
As  the  exudate  becomes  less  abundant,  change  to  a  dry  dressing  and 
change  the  packing  in  the  canal  every  other  day.  Smaller  drains 
may  be  inserted  about  the  tenth  day,  and  are  removed  entirely  when 
the  suppuration  shall  have  ceased. 

As  Veau  says,  this  intervention  is  only  the  first  act  of  a  prolonged 
and  tedious  process  and  this  the  family  should  understand  beforehand. 
After  several  months,  it  may  be  necessary  to  remove  some  necrosed 
hone ;  and,  long  after  the  <ure  appears  t  omplete,  the  trouble  may  recur. 


374  ACUTE    OSTEOMYELITIS. 

OSTEOMYELITIS  OF  THE  UPPER  END  OF  THE 
HUMERUS. 

Begin  the  incision  a  finger's  breadth  below  the  clavicle,  following 
the  axis  of  the  humerus.  Prolong  it  downward  five  or  six  inches.  The 
incision  will  traverse  the  deltoid  near  its  anterior  border.  Separating 
the  lips  of  the  wound,  divide  the  periosteum  and  proceed  to  trephine 
and  drain  as  in  the  preceding  case  (Fig.  281). 


Fig.  281. — Osteomyelitis  of  the  humerus.      (Marsee.) 

OSTEOMYELITIS  OF  THE  LOWER  END  OF  THE 
HUMERUS. 

Make  an  incision  eight  to  fifteen  inches  in  length  in  the  line  of, 
and  ending  below  at,  the  external  condyle.  The  incision  will  traverse 
the  thick  fibers  of  the  triceps.  Trephine  and  drain.  If  it  is  necessary 
to  make  an  internal  counter-opening  for  a  drain,  remember  the  situa- 
tion of  the  ulnar  nerve.  If  the  whole  bone  is  affected,  the  same  prin- 
ciples are  involved.     The  prognosis  is  exceedingly  grave. 

OSTEOMYELITIS  OF  THE  LOWER  END  OF  THE  FEMUR. 

Make  the  incision  along  the  antero-internal  border  of  the  thigh, 
traversing  the  fleshy  vastus  internus. 


OSTEOMYELITIS  OF    I  III     FEMUR. 


The  femoral  vessels  are  behind  this  line.  The  bone  is  deeply 
■laced  an.l  the  operation  difficult,  but  trephine  thoroughly.  Drain 
the  medullary  cavity  and  die  periosteal  abscess  (Fig.  2S2). 


Fn;.  282. — Cross  section  showing  manner  of  placing  drains  after  trephining 
the  femur,     i  Veau.) 

I  >S  I EOM.YELITIS  OF  THE  UPPER  EXTREMITY   OF  THE 

FEMUR. 
Make  the  incision  along  the  outer  surface  of  the  thigh  over  the  great 
trochanter.     Divide  the  aponeurosis  of  the  gluteal  muscle,  trephine, 

and  drain. 


CHAPTER  XX. 
SEPTIC  ARTHRITIS. 

Septic  arthritis  is  acute  purulent  inflammation  of  the  joints,  due 
to  the  presence  of  an  infective  agent,  more  frequently  the  staphylo- 
coccus or  the  streptococcus.  The  infection  may  reach  the  joint 
through  a  wound,  by  way  of  the  blood  vessels  or  through  the  lymph 
channels. 

This  purulent  inflammation  follows,  then,  direct  injury,  or  is  a  se- 
quel to  various  infective  diseases,  such  as  typhoid  fever,  gonorrhea, 
scarlet  fever,  or  osteomyelitis;  but  by  no  means  are  all  the  joint  inflam- 
mations following  these  conditions  purulent. 

Purulent  inflammations  are  to  be  distinguished  from  non-septic 
inflammation  both  by  the  symptoms  and  the  physical  signs.  The 
symptoms  are  those  belonging  to  sepsis,  for  here  it  exists  in  a.  high 
degree.  The  tongue  is  brown  and  the  temperature  is  very  high,  the 
pulse  is  weak  and  rapid,  there  are  the  appearances  of  prostration  and 
finally  delirium  ensues.  The  pain  is  extreme  and  aggravated  by  the 
least  touch.  With  respect  to  the  physical  signs,  there  is  marked  swell- 
ing of  the  joint  and  the  skin  is  red  and  edematous,  not  only  over,  but 
above  and  below  the  joint,  and  fluctuation  is  usually  to  be  detected. 

Treatment. — This  is  an  emergency  of  the  first  rank.  It  is  an  in- 
tervention designed  to  save  the  function  of  the  joint;  and  sometimes 
even  life  is  threatened. 

There  is  but  one  indication,  once  the  diagnosis  is  made,  viz.: — to 
open  the  joint  by  free  incision  and  counter-incision,  that  every  part 
of  it  may  be  reached  and  drained. 

The  most  careful  antisepsis  is  to  be  observed.  The  limb  is  to  be 
as  carefully  cleansed  as  if  no  pus  was  expected. 

Scrub  the  skin  over  the  joint  (the  knee,  for  example),  the  upper 
third  of  the  leg,  and  lower  third  of  the  thigh  with  soap  and  water  and 
with  ether  and  bichloride.     Sterilized  instruments  are  to  be  used; 

376 


AB  rHROTOlfV    <>l    THE    K\l  I  . 


377 


they  arc  simple,  a  scalpel    a  few  artery  Forceps,  some  rubber  drains, 
and  an  irrigator.    The  whole  aim  is  to  secure  ample  drainage  and 

subsequent  antisepsis,  and  nature  will  take  care  of  the  rest.     In  cer- 
tain of  the  joints,  however,  mere  incision  may  not  be  sufficient  and 

excision  must  be  added. 


Fig.  283. — Septic  Arthritis.     Incisions  for  drainage  of  the  knee.     (Veau.) 


Arthrolomy  of  the  Knee. — Sepsis  affecting  the  knee-joint  causes  the 
knee  to  become  enlarged,  globular  in  outline,  painful,  reddened, 
edematous,  with  constitutional  symptoms  of  sepsis.  The  operation, 
Dnder  general  anesthesia,  is  very  simple  and  without  danger.  The 
important  thing  is  to  open  freely.  Two  incisions  are  to  be  made,  one 
external  and  one  internal  (Fig.  283). 


378 


SEPTIC  ARTHRITIS. 


External  Incision. — Locate  the  lower  border  of  the  patella ;  and,  be- 
ginning a  little  below  this  line,  make  an  incision  parallel  with  the 
external  border  of  the  patella  and  ending  about  two  fingers'  breadth 
above  its  upper  border,  which  will  be  near  the  upper  limit  of  the  syno- 
vial sac.  This  incision  traverses  the  integument  and  beneath  it  the 
firm  aponeurosis  of  the  vastus  externus.  As  the  joint  cavity  is 
reached,  very  often  the  pus  spurts  out  with  great  force. 


Fig.  284. — Drawing  the  transverse  drain  into  place.     (Veau.) 

Internal  Incision. — On  the  inside,  make  an  incision  symmetrical 
with  the  first,  but  a  little  further  removed  from  the  internal  border  of 
the  patella.  The  aponeurosis  is  here  less  firm,  but  the  synovial  cavity 
is  deeper;  the  swelling  is  usually  greater  on  the  inner  side.  Some 
of  the  fleshy  fibers  of  the  vastus  internus  are  always  divided.  The 
cavity  is  not  so  easily  reached  as  on  the  outer  side. 

Drainage. — Place  a  large  transverse  drain  (Fig.  284).  But  in  some 
cases  this  is  not  sufficient.  The  lateral  diverticula  of  the  synovial 
sac  must  be  drained  separately  (Fig.  285).  For  this  two  counter- 
openings  are  required,  one  on  each  side.     Into  one  of  the  incisions 


ARTHROTOMY    OF   Till     KN1  I  . 


379 


Fig.  285. — Cross  section  of  knee-joint  showing  that  the  transverse  tube  drains  the  upper 
part;  the  two  lateral  tubes  the  inferior  part  of  the  synovial  sac.      (Veau.) 


Fir..   28(1.     Manner  of  making  posterior  counter  opening  for  drainage 
of  the  knee.      ( I  ,  ■ 


38o 


SEPTIC  ARTHRITIS. 


at  its  lower  part,  introduce  forceps,  and  push  backward  and  downward 
through  the  synovial  sac  at  the  level  of  the  interarticular  line  (Fig. 
286).  If  it  is  an  old  arthritis,  this  is  not  difficult;  but  in  the  case  of 
a  recent  effusion,  the  ligaments  are  tense,  and  the  articular  surfaces  are 
in  contact  so  that  the  passageway  is  quite  narrow. 

When  the  forceps,  pushed  backward  in  this  manner,  bulges  the  skin, 
open  the  blades,  and,  between  them,  make  an  incision  one  or  two  inches 


Fig.  287. — Septic  Arthritis.     Drainage  of  the  knee  complete.      (Veau.) 

long.     Through  this  opening  in  the  forceps,  draw  a  drainage-tube  into 
place.     Repeat  the  manoeuvre  on  the  opposite  side. 

It  is  better  to  make  the  counter-opening  on  the  external  side  first, 
as  the  ligaments  there  are  less  tense.  The  beginner  is  seldom  success- 
ful in  making  the  opening  internally.  He  nearly  always  pushes  the 
forceps  backward  at  too  high  a  level  and  the  point  engages  in  the  tendon 
of  the  adductor  magnus.     It  must  be  directed  downward  and  back- 


AIMIIKoloUY    OF    THE    KM  I 


3»1 


ward  (Fig.  287).  When  the  joint  is  thus  opened,  irrigate  freely  with 
hot  saline  solution,  reaching  every  recess  of  the  joint  and  wiping  with 
sterile  gauze.  Aim  to  clean  the  whole  synovia.  It  the  joint  is  putrid, 
finish  the  irrigation  with  peroxide.  I><>  nol  suture  the  wounds.  Em- 
ploy a  moist  antiseptic  dressing.  Immobilize  the  limb  on  a  pos 
terior  plaster  splint. 
Subsequent  Treatment. — Irrigate  and  dress  twice  daily  for  the  first 


Fig.  288. — Puncture  of  the  knee.     (Lcjors.) 


few  days.     However,  if  the  temperature  falls  almost  to  normal  and  the 
pain  ceases,  do  not  be  in  a  hurry  to  change  the  first  dressing. 

If  the  suppuration  diminishes  about  the  end  of  the  first  week,  put  in 
a  smaller  drain  in  the  same  manner  as  before,  and  employ  dry  dressings. 
Watch  the  temperature.  A  rise  indicates  a  retention  of  pus  and  calls 
for  new  drainage.  Endeavor  to  avoid  permanent  flexion  of  the  leg, 
a  matter  of  the  greatest  difficulty  and  of  the  greatest  importance,  for 
such  flexion  cannot  be  corre<  ted. 


382 


SEPTIC  ARTHRITIS. 


After  the  second  week  the  lateral  drains  are  removed;  and,  some 
days  later,  the  transverse  drain.  After  a  month,  if  the  inflammation 
is  all  gone,  attempt  passive  motion;  but  it  is  almost  a  certainty  that 
the  joint  will  be  stiff;  still  if  it  is  stiffened  in  extension,  there  is  no 
occasion  for  reproach. 

PUNCTURE  OF  THE  KNEE-JOINT. 

Occasionally  it  is  desirable  to  empty  the  knee-joint,  as  in  the  case 
of  a  voluminous  hemarthrosis  or  serous  exudation.     The  same  careful 


'       AM 
Fig.  289. — Arthrotomy  of  the  ankle.     Trace  of  the  incisions.      (Veau.) 


asepsis  is  practised  as  for  arthrotomy.  Locate  the  upper  external 
angle  of  the  patella  (Fig.  288).  A  little  above  and  to  the  outside  of 
this  point,  plunge  the  trocar  directly  into  the  joint.  The  structures 
here  are  quite  resistant,  but  there  are  no  vessels  likely  to  be  wounded. 
As  the  exudate  flows  out.  gently  compress  the  joint  to  empty  it.  With- 
draw the  trocar  with  a  quick  movement,  apply  a  sterile  dressing,  and 
bandage  the  knee  in  absorbent  cotton. 


[NCISIONS    FOB    DRAINAGE    <>l     Wkl.i    JOINT.  383 

ARTHRt  )T\  iMV  <  >F  THE  ANKLE  JOINT. 

Tin's  operation  Is  not  so  frequent!)  required  as  for  the  knee.  ( Iften 
local  anesthesia  will  suffice.  Make  the  first  incision,  two  inches  in 
Length,  over  the  anterior  border  of  the  external  malleolus  and  reaching 
a  little  below  its  tip  (Fig.  2S9).  in  the  upper  part  of  the  in<  ision, 
one  may  cut  freely  down  to  the  hone,  but  in  the  lower  pari  more  1  are 
must  be  used.  Some  small  arteries  may  he  divided  if  one  goes  too 
deep 


yj/. 

PlG.  290. — Septic  Arthritis.      Drainage  of  the  ankle-joint.      (Vcau.) 

In  the  middle  of  the  incision,  open  the  joint,  enlarge  the  orifice, 
and  mop  out  the  cavity. 

Introduce  an  artery  forceps  and  carry  it  through  the  joint  cavity 
to  the  opposite  side,  and  over  its  point  make  a  counter-opening  (Fig. 
290).  This  opening  should  fall  over  the  tip  of  the  inner  malleolus. 
As  the  forceps  is  withdrawn,  it  pulls  a  drainage-tube  into  place  (I''i,L,r.  291). 

Dressing  and  subsequent  care  are  the  same  as  in  the  knee. 


3§4 


SEPTIC  ARTHRITIS. 


ARTHROTOMY  OF  THE  ELBOW-JOINT. 
Make  a  vertical  incision  three  inches  in  length,  with  its  center  over 
the  outer  border  of  the  apex  of  the  olecranon,  dividing  some  of  the 
fibers  of  the  triceps  and  anconeus  (Fig.  292).  Puncture  the  synovial 
cavity  at  the  middle  of  the  incision  and  enlarge  the  opening  to  corre- 
spond with  the  incision.     Push  a  forceps  transversely  through  the 


Fig.  291. — Septic  Arthritis  of  ankle.     Drainage  placed.      (Veau.) 

joint  at  the  upper  level  of  the  olecranon.  Over  its  point  make  the 
internal  vertical  incision.  Cut  carefully,  for  the  ulnar  nerve  is  here 
in  close  contact  with  the  posterior  surface  of  the  inner  condyle. 

Draw  a  drain  into  place  with  the  forceps.     The  dressing  and  sub- 
sequent care  is  the  same  as  that  described  for  the  knee. 

ARTHROTOMY  OF  THE  WRIST. 

Make  an  external  incision  between  the  long  extensors  of  the  thumb 
and  the  extensors  of  the  index-finger,  lines  which   may  always  be 


ARTHROTOMY    OF    TIM      IMP. 


3»5 


fctermined.     Make  a  second  incision  on  the  ulnar  side  between  the 

tendons  of  flexor  and   extensor   carpi    ulnaris.      The   two   incisions 
may  be  connected  by  pushing  through  a  grooved  director. 

ARTHROTOMY  OF  THE  SHOULDER. 

The  joint  may  be  opened  by  a  vertical  incision,  beginning  at  the 
.nterior  angle  of  the  acromion  process  and  cutting  downward  in  the 


Fig.  292. — Septic  Arthritis  of  elbow.     Incisions  for  drainage.     {Veau.) 

line  of  the  bicipital  groove,  or  the  joint  may  be  opened  behind  along 
the  posterior  border  of  the  deltoid,  splitting  the  tendons  of  the 
infraspinatus  and  teres  minor. 

ARTHROTOMY  OF  THE  HIP. 

The  hip-joint,  deeply  set  under  a  thick  muscular  mass,  may  be 
reached  either  from  in  front  or  behind.  The  aim  of  any  procedure  is 
to  reach  the  articulation  in  such  manner  as  to  produce  the  least  de- 
struction possible  in  these  periarticular  muscles;  and,  therefore,  one 
must  seek  the  intermuscular  spaces,  or  split  the  various  muscles  in 
the  direction  of  their  fibers. 
25 


386 


SEPTIC   ARTHRITIS. 


The  study  of  the  anatomy  of  the  region  demonstrates  that  several 
pathways  to  the  joint,  complying  with  the  above  conditions,  can  be 
found. 

In  front,  the  joint  is  covered  by  several  muscles  whose  directions 
correspond  to  the  axis  of  the  thigh,— the  pectineus,  the  iliopsoas,  the 
rectus  femoris,  in  direct  contact  with  the  capsule;  the  sartorius  and 
the  fascia  lata  more  superficially  placed. 

Behind,  the  joint  lies  under  a  group  of  muscles  which  are  parallel  to 
it  when  flexed  at  an  angle  of  45 °.     These  are  arranged  in  two  layers;  ■ 
in  the  first,  the  g.  maximus;  in  the  second,  the  g.  medius  and  the  ob- 
turator internus  and  gemelli;  while  below  and  behind  is  the  tendon  of 
the  obturator  externus. 

anterior  arthrotomy. — If  one  wishes  to  reach  the  joint  from  in 
front,  he  may  pass  (1)  in  between  the  fascia  lata  and  the  gluteus  medius 
externally  and  the  rectus  and  sartorius  internally. 

(2)  Between  the  rectus  and  sartorius  externally  and  psoas  internally. 

(3)  Through  the  sheath  of  the  psoas. 

In  the  first  case,  the  outer  end  of  the  neck  and  the  great  trochanter 
is  exposed.  In  the  second,  the  inner  end  of  the  neck,  and  in  the  third, 
the  head  of  the  femur. 

Position. — On  the  back  with  legs  extended.  Operator  stands  at 
outside  with  assistant  opposite,  and  second  assistant  moves  the  leg 
as  directed. 

Incision. — (1)  Incision  begins  above,  and  finger's  breadth  inside,  of 
ant.  sup.  spine,  and  extends  downward  and  inward  parallel  to  sartorius, 
for  four  inches.  Expose  the  internal  border  of  sartorius,  draw  it 
outward.  Below  it  will  be  exposed  the  rectus  to  be  drawn  outward 
also.     The  psoas  is  exposed  and  drawn  inward  to  expose  the  capsule. 

(2)  The  incision  begins  directly  over  the  ant.  sup.  spine,  and  descends 
nearly  vertically,  bisecting  the  angle  between  the  sartorius  and  tensor 
fascia  lata.  The  sartorius  and  rectus  are  drawn  inward  and  the 
capsule  exposed. 

(3)  Finally,  the  incision,  to  follow  the  outer  border  of  the  psoas,  may 
begin  at  the  inner  third  of  Poupart's  ligament  and  extend  downward 
and  slightly  inward.  The  psoas  is  exposed  near  its  inner  border  and 
opened,  avoiding  the  anterior  crural  nerve. 


IRTHROTOin    01    mi'-  J87 

( )pen  the  ( 'apsule.-  <  >nce  the  capsule  is  exposed,  whatever  the  route, 
the  muscles  are  to  be  relaxed  by  flexion,  abduction,  and  external  rota- 
Inn  which  favors  their  retraction.  The  capsule  thus  freely  exposed  is 
incised  to  any  extent  necessary. 

Counter-opening  in  Capsule. — It  may  be  advisable  to  make  an  in- 
ternal incision  to  secure  complete  drainage.  Make  an  incision  from 
the  external  border  to  the  pubes  downward  and  outward,  exposing 
the  span-  between  the  pectineus  and  adductor  longus.  Avoid  the 
obturator  nerve.  Next  introduce  a  forceps  into  the  opening  already 
made  in  the  capsule  and  let  the  point  emerge  at  the  second  opening; 
and,  on  this  point  as  a  guide,  the  counter-opening  is  made.  The 
force]  >s  is  used  to  draw  a  large  drainage -tube  into  place. 


CHAPTER  XXI. 

FOREIGN  BODIES. 

THE  EYE. 

Foreign  bodies  lodged  on  the  conjunctiva  or  cornea  are  painful,  and 
may  soon  provoke  a  conjunctivitis,  more  or  less  severe. 

The  offending  particle  may  be  concealed  under  the  lid  or  be  im- 
bedded in  the  cornea.  The  latter  is  especially  likely  to  be  the  case 
with  those  who  have  to  do  with  emery  wheels. 

The  patient's  sensation  is  a  very  poor  guide  in  locating  the  object; 
if  it  is  on  the  cornea,  he  is  likely  to  be  certain  it  is  under  the  upper  lid. 

Begin  by  inspecting  the  eye  under  a  good  light  and  at  various  angles. 
Pull  down  the  lower  lid,  instructing  the  patient  to  look  upward.  Evert 
the  upper  lid.  This  is  done  by  grasping  the  eye-lashes  between  the 
thumb  and  fore-finger  and  pulling  downward,  at  the  same  time  making 
pressure  upon  the  tarsal  cartilage  of  the  lid  with  a  pencil,  stylet,  or 
the  opposite  thumb.  Instruct  the  patient  to  look  downward.  Com- 
bined with  this  pressure,  the  eyelashes  are  now  pulled  upward  and 
in  this  manner  the  lid  is  everted  and  exposed  to  inspection.  The 
novice  does  better,  perhaps,  to  stand  behind  the  patient,  but  the  special- 
ist, sits  in  front  of  the  patient  and  turns  the  lid  with  one  hand. 

If  the  foreign  body  is  free,  it  is  readily  picked  up  with  the  point  of 
the  stylet  wrapped  with  cotton,  but  if  it  is  imbedded  in  the  cornea, 
considerable  curettement  may  be  required  to  dislodge  it.  The  in- 
strument must  be  sterile,  otherwise  corneal  ulcer  may  follow  the  manip- 
ulation. In  the  case  of  nervous  or  sensitive  individuals  or  when  the 
conjunctiva  is  much  congested,  the  manipulation  must  be  preceded  by  j 
the  instillation  of  a  few  drops  of  a  4  per  cent,  solution  of  cocaine,  which 
should  be  fresh  and  must  be  sterile.  Everything  used  must  be  sterile — 
hands,  instruments,  cotton,  and  solutions. 

Following  the  extraction,  irrigate  with  normal  salt  solution  and  in- 
still two  drops  of  2  per  cent,  collargolum  solution  or  10  to  25  per  cent. 

388 


FOREIGN    BODE  s    in    mi     i  \i\  389 

argyrol  solution  and  direct  the  patient  t>>  wash  1 1 1  *  -  eye  frequently  with 
thoracic  <»r  normal  salt  solution;  if  there  is  much  congestion,  bandage 
the  eye  for  one  <>r  two  days. 

If  tin-  foreign  body  has  penetrated  to  the  anterior  chamber,  the  iris, 
or  the  posterior  chamber,  the  immediate  treatment  must  be  limited 
to  such  measure  as  will  prevent  infection — boracic  irrigation  and  hand- 
age — until  the  case  can  be  placed  in  the  hands  of  a  specialist  or  until 
Bpecial  text-books  can  be  carefully  consulted. 

1 1  may  be  necessary  to  employ  the  X-ray  in  diagnosis  in  these 
cases.  The  extraction  may  require  a  delicate  operation  or  the  use  of 
the  electro-magnet,  and  finally  the  removal  of  the  globe  may  be 
necessary. 

Chemical  irritants  should  be  removed  by  free  irrigation.  For  lime 
in  the  eye,  a  solution  of  sugar  in  vinegar  is  recommended,  the  sugar 
forming  a  soluble  compound  with  the  lime.  A  few  drops  are  used, 
followed  by  free  flushing  with  water.  Afterward  atropine,  gr.  1 
to  the  ounce  is  imperative. 

THE  EAR. 

,  The  foreign  bodies  most  frequently  found  in  the  ear  are  pebbles, 
shoe-buttons,  peas,  beans,  pens,  pieces  of  tooth-pick,  pieces  of  cotton. 
etc.,  etc. 

Children  may  place  these  objects  in  their  ears  in  play  or  innocent 
kperimentations  or  adults  may  meet  with  the  accident,  attempting 
to  relieve  an  itching  in  the  auditory  canal.  A  tampon  may  be  left 
in  the  ear  by  the  doctor.  The  body  usually  lodges  in  the  outer  part  of 
the  canal,  and  only  reaches  the  tympanic  membrane  after  ill-advised 
efforts  at  extraction. 

The  pain  and  discomfort  are  usually  moderate;  and,  as  a  rule,  there 
are  no  very  urgent  indications  for  intervention.  But  if  the  object 
rests  against  the  drum,  the  pain  is  severe  and  may  even  produce  mental 
disturbance. 

The  first  thing  to  do,  then,  is  always  to  confirm  the  diagnosis.  The 
iatient's  belief  in  the  matter  must,  under  no  circumstances,  be  ac- 
cepted as  final.     There  is  only  one  way  to  confirm  the  diagnosis;  and 


39° 


FOREIGN   BODIES. 


that  is  by  careful  inspection  of  the  whole  canal,  if  the  object  is  not  seen 
in  the  outer  portion. 

Draw  the  external  ear  upward  and  backward,  and  the  tragus  for-  j 
ward.     Under  good  illumination  and  with  the  aid  of  a  head-mirror  \ 
and  otoscope,  the  drum  is  readily  seen.     If  nothing  can  be  seen,  and 
provided  there  have  been  no  blind  efforts  at  extraction,  it  may  be  defi- 
nitely concluded  that  the  patient  is  mistaken. 

If,  on  the  other  hand,  you  locate  the  object,  do  not  hurriedly  intro- 
duce a  forceps  into  the  ear  seeking  to  grasp  the  object;  unless,  indeed, 
it  is  of  such  a  nature  that  it  may  be  easily  seized,  for  you  will  almost 
always  make  matters  worse,  pushing  it  further  into  the  canal.     Re- 


Fig.  293. — Ear  Forceps. 

member  that  however  desirable  it  may  be  to  empty  the  ear,  there  is, 
as  a  rule,  no  great  urgency  in  the  matter  and  you  have  plenty  of  time 
to  take  counsel  with  yourself  (Fig.  293). 

In  some  cases,  a  small  hooked  instrument  may  be  cautiously  pushed 
past  the  object  and  withdrawn,  pulling  the  object  out,  or  a  small  blunt 
curette  may  be  similarly  employed.  Usually  a  large  syringe  is  the 
proper  instrument.  Throw  a  stream  of  warm,  sterile  water  into  the 
ear  with  the  purpose  of  forcing  the  body  out  by  the  "vis  a  tergo." 

To  inject  the  stream  properly,  lift  the  pinna  upward  and  backward 
as  in  inspection,  and  direct  the  stream  along  the  posterior  superior  wall, 
using  moderate  force.  Use  one  syringeful  after  another,  until  the 
offending  substance  is  washed  away  or  the  patient  is  tired  out. 


FOR]  ii. \    BODIl  S    in    mi     NOS1  ,  39] 

If  you  have  failed,  instill  into  the  car  a  few  drops  of  glycerine  or 
warm  oil,  lightly  tampon,  and  dire<  I  the  patient  to  sleep  on  the  affe<  ted 
hide,  returning  the  next  day  for  another  trial.  The  chances  are  greatly 
in  favor  of  ultimate  success  without  injury  to  the  ear. 

In  the  case  of  a  live  insect  in  the  ear,  till  the  ear  with  oil  and  sub- 
sequently the  "cadaver"  may  be  removed  by  irrigation. 

If  "instrumentation"  seems  advisable,  there  must  be  no  blind 
grasping  for  the  object— it  must  be  kept  clearly  in  view.     It  has 

happened,  in  violation  of  this  rule,  that  the  middle  ear  has  been  in- 
vaded and  the  ossicles  dragged  out.  Death  has  occurred  from  such 
manipulation,  though  the  post-mortem  showed  that  no  foreign  body 
had  ever  been  present. 

In  the  case  of  children,  instrumental  extraction  will,  as  a  rule,  re- 
quire an  anesthetic.  If  the  ear  has  become  much  inflamed  or  the 
body  pushed  through  the  drum,  the  case  is  one  for  the  specialist. 

On  the  whole,  the  practitioner  might  adopt  the  rule,  that  if  left  in 
the  ear,  untouched,  the  foreign  body  is  less  likely  to  do  harm  than  rude 
and  maladroit  efforts  at  removal. 

THE  NOSE. 

The  catalogue  of  bodies,  recorded  as  lodged  in  the  nose,  is  long. 
Naturally,  children  are  more  frequently  the  subject  of  these  mishaps, 
although  lunatics  and  hysterical  women  may  intentionally  plug  the 
nose.  Occasionally,  a  foreign  body  previously  swallowed,  may  be 
coughed  up  and  lodge  in  the  posterior  nares.  Pledgets  of  cotton  and 
pieces  of  gauze,  which  have  been  used  as  tampons,  may  be  overlooked 
and  a<  t  as  foreign  bodies. 

In  the  case  of  the  irresponsible,  the  presence  of  a  foreign  body  may 
not  be  suspected,  so  few  are  the  symptoms,  until  there  develops  a 
profuse  sero-mucous  discharge.  There  may  be  frequent  attacks  of 
sneezing;  and,  if  the  body  remains  long,  the  mucous  membranes  be- 
come swollen  and  perhaps  the  skin  of  the  affected  side  also.  There 
may  be  headache  or  facial  neuralgia.  These  foreign  bodies  should  be 
removed  as  soon  as  possible,  first  having  determined  their  nature,  size, 
and  situation. 

Begin  by  a  careful  examination  of  the  anterior  nares;  and,  if  this  is 


392 


FOREIGN   BODIES. 


not  sufficiently  instructive,  examine  the  posterior  nares  by  hooking 
the  finger  up  behind  the  soft  palate.  The  examination  and  removal 
are  often  facilitated  by  the  use  of  cocaine,  and  in  the  case  of  children, 
a  few  whiffs  of  chloroform  may  be  necessary. 

Chloroform  is  also  the  effectual  remedy  for  animate  foreign  bodies, 
such  as  insects  and  maggots.  Used  in  this  manner,  it  is  not  inhaled, 
but  is  shaken  up  with  an  equal  amount  of  water  and  syringed  into  the 
nose  before  the  two  ingredients  separate. 


Fig.  293a. — Angular  forceps  for  foreign  body  in  the  nose. 

A  body  lying  in  the  anterior  nares  is  usually  readily  removed  by  a 
mouse- toothed  forceps;  or  a  curved  probe  or  small  curette  may  be 
necessary  to  dislodge  it.  An  angular  forceps  is  sometimes  convenient 
(Fig.  293  a).  In  other  cases,  the  obstruction  may  be  removed  by 
drawing  a  tampon  through  the  nasal  cavity  from  behind,  as  recom- 
mended by  Sajous. 

If  the  body  is  lodged  in  the  posterior  nares,  it  is  usually  pushed 
backward  into  the  pharynx,  care  being  taken  that  it  does  not  drop 
down  into  the  larynx  or  esophagus. 

"In  the  case  of  infants,  a  small  body  may  be  removed  by  blowing 
forcibly  into  the  mouth."   (John  J.  Kyle.) 

PHARYNX  AND  ESOPHAGUS. 

Many  diverse  objects  may  lodge  in  these  passageways,  either 
through  ineffectual  efforts  at  swallowing  or  by  inadvertently  slipping 


TREATMENT   "l     FOREIGN    BODIES    IN    Mil.    I'HXKVW. 


393 


from  the  mouth.      False  teeth   arc-  often  loosened  and  carried  into  the 
pharynx  or  esophagus  during  sleep. 

The  point  of  Lodgment,  the  immediate  effect,  the  dangers,  and 
tin-  difficulty  of  removal,  depend  upon  the  size  and  shape  of  the 
obje<  t. 

The  pharyngo  esophageal  canal  is  narrowest  behind  the  larynx, 
opposite'  the  cricoid  cartilage  and  the  sixth  cervical  vertebra;  at  this 
point  a  Large  body  is  likely  to  lodge.  A  second  constriction  lies  two 
and  three-quarter  inches  further  down,  behind  the 
Left  bronchus;  and  a  third  where  the  esophagus 
passes  through  the  diaphragm.  Larger  bodies, 
then,  are  liable  to  lodge  opposite  the  larynx. 
Sharp  and  pointed  objects,  such  as  needles  and 
fishbones,  may  anchor  at  any  point  without  refer- 
ence to  the  caliber  of  the  conduit. 

The  immediate  effects  of  the  lodgment  of  a 
foreign  body  vary  from  instant  asphyxia  to  merely 
slight  difficulty  in  swallowing.  Later  there  may 
occur,  even  in  the  case  of  a  slight  obstruction,  the 
dangerous  conditions  following  infection — erosion 
of  the  walls,  perforation  of  the  bronchi  or  lungs, 
of  the  pericardium,  the  aorta,  or  carotids — one 
bas  but  to  think  of  the  numerous  relations  of  the 
esophagus  in  the  neck  and  thorax  to  understand 
how  diverse  the  consequences  of  such  spreading 
infection  might  be  in  various  cases. 

Very   naturally,   the   deeper   down    the   object      Fig.  294.— Horse-hair 
lodges,  the  greater  the  difficulty  in  locating  and    closed^' 
reaching  it. 

Treatment. — Asphyxia,  due  to  occlusion  of  the  lower  part  of  the 
pharynx  involving  the  larynx,  demands  immediate  action.  The 
patient  is  Livid,  gasping,  and  struggling.  Run  the  finger  into  the 
throat  over  the  epiglottis,  where  the  body  may  be  felt  and  hooked 
out.  If  you  fail  in  this,  do  not  waste  time  in  these  cases  of  extreme 
urgency,  trying  tentative  measures,  such  as  inversion,  but  do  a //(/'<//<- 
otomy,  or  laryngotomy  in  the  adult  (see  page  414).    After  the  operation, 


394  FOREIGN   BODIES. 

the  foreign  body  may  be  expelled  spontaneously  in  the  efforts  of  cough- 
ing or  vomiting. 

In  the  less  urgent  cases,  the  first  indication  is  to  confirm  the  diagno- 
sis and  definitely  locate  the  object.  The  sensation  of  the  patient  is  not 
sufficient  index  as  to  the  presence  and  situation  of  an  obstruction  in 
the  gullet,  for  the  pain  may  be  due  to  a  wound  made  by  the  foreign 
body  in  passing. 

Inspect  the  mouth,  the  fauces,  and  the  tonsils.  Palpate  the  region 
of  the  glottis  and  behind  the  soft  palate.  Palpate  externally  along  the 
anterior  border  of  the  sternomastoid,  pressing  deeply  to  reach  the 
esophagus,  most  superficial  on  the  left  side.  Even  if  the  foreign 
body  is  believed  to  be  located  in  the  neck,  as  a  result  of  this  palpation, 
it  is  better  to  make  certain  by  passing  an  esophageal  sound. 


Fig.  295. — Coin  catchers. 

In  certain  instances,  the  X-ray  will  be  invaluable,  though  not  al- 
ways to  be  relied  upon.  In  the  hands  of  the  expert,  the  esophagoscope 
has  proved  to  be  useful.  In  the  course  of  time  this  instrument  will 
probably  come  to  be  a  part  of  every  doctor's  "arsenal."  It  not  only 
makes  exact  diagnosis  possible,  but  enables  the  foreign  body  to  be  re- 
moved by  sight,  avoiding  thus  the  injuries  to  the  esophagus  which  blind 
efforts  often  produce. 

The  presence  and  location  of  the  foreign  body  once  established, 
extraction  is  indicated.     Inversion  is  illusory  and  emesis  dangerous. 

If  the  body  is  in  the  pharynx,  it  may  be  seized  with  curved  forceps, 
or  dislodged  with  the  finger  or  an  improvised  hook.  To  employ  the 
forceps,  seat  yourself  before  the  patient,  whose  mouth  is  propped  wide 
open.  When  the  object  is  once  seized,  incline  the  patient's  head  for- 
ward as  the  forceps  is  withdrawn.  If  you  lose  your  hold,  rapidly 
withdraw  the  forceps  and  remove  the  mouth  gag  and  often  the  loosened 
object  will  be  coughed  out. 


I  OR]  l'.\    B s    in    THE    ESOPHAGI  S. 


395 


In  the  cisc  of  an  infant,  place  the  patient  on  its  back  with  the  head 
hanging  over  the  edge  of  the  table,  thufl  preventing  the  body  from 
dropping  into  the  larynx.     (Have  everything  ready  for  tracheotomy.) 

In  extracting  a  body  from  the  esophagus,  the  greatest  caution  is 
necessary  to  prevent  laceration.     Rough  manipulation  only  aggravates 

me  muscular  spasm,  which  is  always  present  in  some  degree,  and  which, 
more  than  anything  else,  prevents  the  body  safely  reaching  the  stomach  : 
and  these  esophageal  muscles  are  exceed- 
ingly strong.  The  esophageal  forceps  is 
used  as  in  the  pharynx. 

The  horse-hair  probang  (Fig.  294), 
introduced  past  the  object,  opened  up 
and  then  withdrawn,  often  succeeds  in  re- 
moving an  implanted  needle  or  fish  bone. 

In  the  case  of  a  coin  or  similarly  shaped 
object    a    "coin   catcher"   may   be  em-  ^ 
ployed    (Fig.    295).       Introduce   the  left 
index-finger    as    a    guide   and   pass   the 
instrument  along  its  posterior  wall  until 
the  coin  is  felt,  when  the  catcher  is  passed 
on    beyond    it.       Now    tilt     the     handle 
forward  and  slowly  withdraw  the  instru- 
ment until  assured  by  the  sense  of  touch 
that   the  coin  is  engaged.       Completely 
withdraw  the  instrument  by  steady,  con- 
tinuous, vertical  traction.     When  the  pharyngeal  orifice  is  reached,  it 
is  necessary  to  accelerate  the  movement  to  achieve  the  final  extract  ion 
(Lejars)  (Fig.  296). 

If,  in  the  course  of  the  manipulation,  the  foreign  body  is  dislodged 
and  slips  on  down  into  the  stomach,  do  not  regard  it  as  a  calamity,  un- 
less the  object  is  very  pointed.  Indeed,  if  the  object  is  deeply  located, 
is  known  to  be  harmless  in  character,  and  extraction  seems  impossible, 
an  effort  should  be  made  from  the  first  to  push  it  on  into  the  stomach 
with  the  esophageal  bougie.  This  should  never  be  done,  if  the  char- 
acter of  the  substance  is  unknown.  No  effort  should  be  prolonged  and 
above  all  else,  no  violence  is  permissible.      Finally,  if  extra*  lion  fails 


Fig.  296. — Extracting  a  coin  from 
the  esophagus.     {Lejars.) 


396  FOREIGN   BODIES. 

and  propulsion  into  the  stomach  is  out  of  the  question,  there  is  only  one 
thing  left  to  be  done — an  esophagotomy. 

In  certain  cases  where  the  body  is  firmly  implanted,  or  when  it  is 
pointed  and  dangerous  to  move,  resort  must  be  made  to  the  operation 
at  once      (See  page  421.) 

LARYNX  AND  TRACHEA.* 

The  air  passage  is  frequently  involved,  an  accident  always  of  con- 
cern, often  serious,  and  sometimes  fatal. 

The  bodies  finding  their  way  into  the  larynx  and  trachea  are  of 
great  variety,  fluid  and  solid,  animate  and  inanimate;  most  often 
aliments  perhaps,  and  after  these,  the  list  may  be  indefinitely  extended. 

Children  are  more  often  the  sufferers,  because  of  their  habit  of  putting 
objects  into  their  mouths  at  random.  Many  times  particles  of  food 
"go  the  wrong  way,"  the  result  of  the  patient's  speaking  or  laughing 
during  the  act  of  swallowing:  the  epiglottis  is  raised  inopportunely,  and 
the  morsel  drops  into  the  larynx.  Small  bodies  are  inhaled  in  ordinary 
breathing.  The  accident  sometimes  happens  during  sleep,  through  the 
dislodgment  of  false  teeth  or  something  held  in  the  mouth;  it  may 
follow  an  attack  of  vomiting,  or  it  may  occur  during  some  operation 
about  the  mouth;  conditions  such  as  anesthesia,  which  diminish 
the  reflex  irritability  or  motility  of  the  larynx,  favor  it. 

The  point  of  lodgment  depends  chiefly  upon  the  size  and  shape  of 
the  object.  Pointed  objects,  such  as  pins  and  fish  bones,  frequently 
stick  in  the  supraglottic  portion  of  the  larynx;  flat  bodies,  coins  and 
buttons,  usually  lodge  in  the  ventricles,  while  small  globular,  heavy 
bodies  descend  into  the  trachea  or  bronchus,  usually  the  right. 

The  symptoms  and  sequelae,  and  therefore  the  dangers,  may  be 
grouped  under  two  heads,  obstructive  and  inflammatory. 

(a)  If  the  body  is  large  and  lodged  in  the  larynx,  asphyxia  may  be 
the  immediate  result  and  may  be  almost  immediately  fatal.  Even 
small  bodies  may  produce  fatal  asphyxia  through  reflex  spasm  of  the 
glottis,  though  usually  the  reflex  spasm  subsides.  Reflexly,  also, 
coughing,  sometimes  violent,  is  induced,  and  this  may  be  the  case 
whether  the  body,  lies  in  the  larynx,  trachea,  or  bronchus.  Sometimes 
*Quotations  are  from  Von  Bergman. 


TREATMENT   01    FOREIGN    BODIES   IN  TT1F.   LARYNX.  397 

the  body  may  lodge  between  the  vocal  cords,  thus  preventing  their 
closure  and  allowing  some  air  to  pass  so  that  life  may  be  sustained 
for  some  time. 

It"  the  body  is  lodged  in  the  ventricles,  there  may  not  be  SO  much 
obstruction,  but  there  is  hoarseness  or  aphonia  and  cough. 

If  the  body  descends  into  the  trachea,  there  may  be  no  indication  of 
obstruction,  but  there  is  much  reflex  irritation,  evidenced  by  pain  and 
cough.  If  the  body  is  light,  it  may  move  backward  and  forward  in 
the  trachea,  following  the  current  of  air. 

If  a  bronchus  is  obstructed,  a  whole  or  a  portion  of  the  lung  may 
collapse,  evidenced  by  altered  pulmonary  sounds. 

(b)  The  body  may  become  encysted  if  not  removed,  or  inflamma- 
tion may  ensue  with  the  most  diverse  sequences,  depending  upon  the 
location  of  the  object:  edema  of  the  glottis,  diphtheritic  inflammation, 
abscess  of  the  larynx,  phlegmon  of  the  neck,  hemorrhage  due  to  erosion 
of  the  large  vessels  or  even  of  the  heart,  tracheitis,  bronchitis,  bron- 
chiectasis, pneumonia,  gangrene  of  the  lung,  empyema,  purulent  peri- 
carditis, mediastinitis,  or  phthisis. 

Tt  eat  mail. — Asphyxia  demands  immediate  action;  there  is  no  time 
for  examination  and  inquiry.  Make  a  hurried  effort  to  remove  the 
body  by  passing  the  finger  into  the  larynx,  and  if  this  fails,  without 
further  delay  do  a  tracheotomy  (see  page  414). 

In  the  less  urgent  cases,  one  may  be  more  deliberate,  endeavoring 
to  ascertain  the  character  of  the  object  and  to  locate  the  point  of  lodg- 
ment. The  history  of  the  case,  the  symptoms  and  the  physical  signs 
derived  from  auscultation,  will  furnish  valuable  information. 

Various  procedures  are  recommended. 

"Inversion  and  violent  shaking  of  the  body  do  not  enjoy  their 
former  popularity.  Even  the  conservative  Weist  considers  manipula- 
tion of  this  sort  dangerous  and  only  justifiable  after  tracheotomy." 

Still  it  does  not  seem  likely  that  it  can  result  in  harm  if  the  body  is 
known  to  be  small  so  that  it  may  readily  pass  between  the  vocal  cords. 

"The  simplest  way  is  to  follow  the  suggestion  of  Sanders,  and  let 
the  body  hang  over  the  edge  of  the  bed  and  rest  on  the  hands  during 
the  attack  of  coughing."  "Generally  speaking,  emetics  are  unreliable 
and  their  use  not  without  danger." 


398 


FOREIGN   BODIES. 


If  there  is  time,  the  laryngoscope  may  be  of  great  aid  in  diagnosis 
and  extraction,  employing  cocaine  in  the 
adult  and  chloroform  in  children. 

In  the  hands  of  the  skilled,  the  broncho- 
scope often  furnishes  a  happy  solution  to  the 
difficulty  (Fig.  297).  It  is  to  be  hoped  that 
the  technic  of  bronchoscopy,  now  familiar 
only  to  the  specialists,  will  soon  be  popular- 
ized with  the  profession  at  large.  In  cases 
less  urgent,  the  X-ray  may  be  used  to 
locate  the  substance. 

But  after  all,  tracheotomy  or  laryngotomy 
is  the  chief  reliance  of  the  practitioner  left  to 
his  own  resources,  and  he  must  be  prepared 
for  immediate  operation  while  other 
measures  are  tentatively  tried.  Lejars  urges 
that  an  attendant  be  at  hand  ready  for  in- 
stant operation  as  long  as  the  body  is  known 
to  be  free  in  the  bronchus  or  trachea. 

"It  makes  no  difference  what  one's  views 
are  regarding  tracheotomy  in  general;  the 
fact  remains  that  no  physician  will  deny  the 
necessity  of  this  step  when  the  danger  of 
suffocation  is  great." 

"The  author  has  become  convinced  that 
the  danger  of  tracheotomy  nowadays  is  insig- 
nificant compared  with  that  of  a  foreign 
body  in  the  air  passages  and  does  not  hesi- 
tate, even  when  the  body  is  situated  in  the 
larynx,  to  remove  the  offending  material 
through  an  incision  should  extraction  per 
vias  naturalis  be  impossible." 

"Tracheotomy    is    positively    indicated 
when  the  foreign  body  is  movable  in  the 
trachea." 
In  any  case  after  the  urgent  symptoms  have  subsided,  "operative 


FOREIGN    BODIES    in    mi     RECTUM.  399 

interference  is  the  special  form  of  treatment  most  rational  and  the 
form  of  operation  depends  upon  the  situation."     "If  the  extraction 
means  laceration,   it  is  justifiable  to  split   the  larynx   itself  or  a  sub 
hyoid  pharyngotomy  may  be  indicated." 

"The  expectant  treatment,  to  which  so  many  patients  formerly 
fell  victim,  is  to  he  condemned.  This  method  is  only  justifiable  in  a 
small  number  of  cases,  in  which  the  body  has  fallen  far  down  into  the 
bronchus  where  it  cannot  he  reached. 

"The  death  rate  shown  by  statistics  should  not  decide  the  question 
of  operation:  the  clinical  picture  of  the  particular  case  and  the  unfortu- 
nate cases  should  guide  the  surgeon.  Those  that  died  after  the  opera- 
tion did  not  do  so  because  they  were  operated  upon,  but  because  they 
were  operated  upon  too  late.  In  an  individual  case  the  doctor  can 
never  count  upon  spontaneous  expulsion.  Every  hour  the  offending 
material  remains  in  situ  lessens  the  chances  more  and  more,  while 
operation  furnishes  conditions  most  favorable  for  its  removal.  Open 
ing  the  air  passages,  then,  is  the  most  rational  procedure  except  for 
the  cases  in  which  endolaryngeal  methods  can  be  used." 

RECTUM. 

The  objects  which  have  been  removed  from  the  rectum  at  one  time 
or  another,  cover  a  wide  range — bottles,  pieces  of  wood,  etc.,  pushed 
in  to  stop  a  diarrhea,  to  satisfy  a  perverted  sexual  impulse,  or  by  the 
insane. 

It  is  scarcely  necessary  to  indicate  all  the  instruments  and  artifices 
which  have  been  employed  in  their  extraction,  but  it  is  helpful,  as 
I. ejars  points  out,  to  formulate  certain  general  rules  of  procedure. 

The  necessity  of  these  formula?  cannot  be  doubted  when  one  con- 
siders the  difficulties  of  extraction,  often  considerable,  and  the  fre- 
quency with  which  the  rectum  is  lacerated  by  misguided  effort. 

Often  the  patient  does  not  admit  the  nature  of  his  difficulty,  con- 
sulting the  doctor  on  some  other  pretext,  such  as  constipation  or 
Some  rectal  trouble  quite  different  from  the  real  condition.  In  the 
case  of  obscure  trouble  in  the  natural  orifices,  the  doctor  should  be  on 
his  guard.  If  the  nature  of  the  complaint  is  admitted,  proceed  to  a 
methodical  examination  ami  endeavor  to  gel  vmir  bearings. 


400 


FOREIGN   BODIES. 


Introduce  a  finger,  which  has  been  well  oiled,  into  the  rectum. 
Sometimes  you  will  find  the  object  just  within  the  orifice,  of  such 
size  and  shape  that  it  can  be  readily  extracted  with  the  finger  or  with  a 
forceps  without  further  trouble,  but  you  cannot  count  too  much  on 
that. 

If  the  examination  shows  it  to  be  lodged  high  up  in  the  concavity 
of  the  sacrum,  impacted  and  perhaps  completely  filling  the  rectum, 
make  no  effort  at  extraction,  but  prepare  for  a  formal  operation. 


Fig.  298. — Foreign  body  in  the  rectum,     b.  Bottle;  c.  Coccyx.     (Lejars.) 


Under  a  general  anesthetic,  put  the  patient  in  the  lithotomy  position 
with  the  thighs  well  flexed,  the  hips  elevated,  and  the  anal  region  in 
a  good  light.  Dilate  the  anus  with  the  fingers  as  completely  as  possible 
and  then  determine  the  exact  "presentation"  of  the  body.  Introduce 
a  Sims'  speculum,  passing  it,  under  the  guidance  of  the  finger,  beyond 
the  coccyx,  and  then  retract  as  widely  as  possible.  This  is  easily 
done  in  the  young,  but  may  be  difficult  in  the  adult. 

When  the  coccyx  is  thus  sprung  back,  the  body  must  be  seized  and 


I  <>Ki  n, \    i ■. -  - 1  ■  1 1  5    r.     i  in     RECTI   \l.  |oi 

t ra 1 1  ii  hi  made  In  the  axis  of  the  outlet  if  the  body  is  long  (a  bottle  for  es 
ample)  and  firmly  fixed  (Fig.  298).     The  fingers  or  forceps  may  be 

used.  If  you  are  dealing  with  glass,  (lie  blades  of  the  forceps  must 
me  t  overed  with  rubber  to  prevent  slipping.  If  the  ends  of  the  foreign 
body  are  pointed,  and  imbedded  in  the  rectal  wall  SO  that  traction  is 
Dangerous,  great  rare  must  be  exercised.  In  some  cases  morcellation 
will  be  possible. 

If  the  coccyx  cannot  be  retracted  and  serves  as  the  direct  impedi- 
ment, it  will  have  to  be  resected.  If  the  body  has  found  its  way  up 
;-to  the  left  iliac  region  into  the  sigmoid,  it  may  possibly  be  worked 
down  into  the  rectum  by  external  manipulation.  Finally,  in  such  a 
cast',  laparotomy  and  opening  the  bowel  may  be  the  only  means  of 
relief. 

( lombs,  of  Indianapolis,  reports  a  case  which  illustrates  the  principles 
of  treatment  involved  (J.  A.  M.  A.,  Oct.  23,  1909). 

After  a  drinking  bout  and  a  drunken  sleep  in  the  woods,  the  patient 
awoke  with  a  pain  in  his  rectum  and  found  it  impossible  to  empty 
his  bowel.  He  applied  to  a  physician  who  discovered  a  beer  glass  in 
the  rectum,  inserted  there  during  the  victim's  drunken  stupor  by 
brutal  comrades.  An  attempt  was  made  to  remove  the  glass  without 
preliminary  divulsion  of  the  sphincter.  During  traction  with  forceps 
the  glass  was  broken  and  the  attempt  failed. 

Some  hours  later  he  was  seen  at  the  hospital  by  Combs  who  found 
the  small  end  of  the  glass  resting  on  the  promontory,  and  the  large 
>end  imbedded  in  the  hollow  of  the  sacrum  (Fig.  298),  its  broken 
t'dges  buried  in  the  soft  tissues.  By  reason  of  the  edema  and  swelling, 
divulsion  was  insufficient  for  removal,  and  consequently  the  contracted 
muscles  were  divided  in  the  middle  line  posteriorly,  when  the  glass,  which 
was  four  inches  long  and  seven  inches  in  circumference  at  its  large  end. 
was  readily  removed.  On  account  of  the  swelling  and  evident  infec- 
tion, the  incision  was  left  to  heal  by  granulation,  and  on  discharge  from 
the  hospital  the  patient  had  a  perfect  control  of  the  sphincter.  Combs 
remarks  that  the  shape,  size,  and  nature  of  the  foreign  body,  the 
edema  and  swelling,  and  the  degree  of  traumatism  will  be  the  guiding 
indications  for  the  course  to  pursue.  It  would  certainly  seem  a  rare 
instance  in  which  amputation  of  the  coccyx  would  be  required.     Ade- 


402 


FOREIGN    BODIES. 


quate  division  of  the  muscles  posteriorly  with  quick  removal  is  advised 
in  lieu  of  prolonged  efforts  at  removal  by  traction,  especially  of  an 
object  with  cutting  edges  from  which  fatal  wounds  may  result. 


THE  URETHRA. 

A  piece  of  sound  may  be  broken  off  in  the  urethra.  Boys  or  the 
insane  may  lose  various  objects  in  the  urethra,  slate  pencils,  pipe  stems, 
pieces  of  watch  chain,  etc. 

As  a  rule,  the  accident  is  not  immediately  disastrous,  for  generally 
the  impediment  to  urination  is  not  complete.  The  object  should 
be  removed  as  soon  as  possible  and  with  as  little  irritation  to  the 
urethra  as  possible. 


Fig.  299. — Urethral  forceps  of  Collin  (a),  Leroy  d'Etiolles  (b),  and  Hunter  (c). 

It  is  necessary  merely  to  enumerate  some  of  the  methods  employed 
successfully  in  various  cases,  and  each  case  must  be  treated  on  its 
own  merits.  Often  the  body  may  be  easily  reached  and  extracted 
with  forceps  (Fig.  299).  In  certain  instances,  it  may  be  gradually 
worked  forward  by  external  pressure;  or  in  urination  the  meatus  may 
be  pinched  up  and  when  the  urethra  is  ballooned  out  by  the  pressure 
of  the  urine,  sudden  release  may  result  in  the  body  being  washed  out. 

In  case  the  body  is  in  the  deeper  part  of  the  urethra,  and  considerable 
manipulation  is  necessary,  pressure  should  be  applied  over  the  urethra 
on  the  bladder  side  of  the  foreign  body,  to  prevent  its  being  pushed 


FOREIGN    BODIES    IN    THE    Ck'l  III kA. 


403 


deeper.  A  piece  of  hollow  sound  or  catheter  may  sometimes  be  re- 
moved by  passing  a  smaller  sound  down  into  its  lumen;  or  the  urethral 
speculum  or  a  larger  hollow  sound  may  be  passed  down  to,  and  over  the 
body,  which  permits  its  more  ready  seizure  by  a  forceps  passed  through 
the  speculum. 

Dayat  shaped  a  lead  sheet  into  the  form  of  a  hollow  sound  and, 
passing  it  beyond  the  object  in  the  urethra,  closed  its  lower  end  by 


Fig.  300. — Extracting  a  pin  from  the 
urethra  by  "  version."  Protruding  the  point 
through  the  skin.      (Bryant.) 


Fig.  301. — Point  grasped  with  forceps. 
Its  direction  reversed  and  head  brought  out 
through  the  meatus.     (Bryant.) 


pressure  over  the  urethra  and  in  removing  the  lead  catheter  the 
foreign  body  came  out  with  it. 

In  another  case,  a  stick  forced  into  the  urethra  could  not  be  with- 
drawn on  account  of  a  hook  on  its  lower  end,  but  after  being  split  into 
many  pieces,  its  extraction  was  accomplished  piecemeal. 

In  the  case  of  a  pin  lost  in  the  urethra  hea  '  dow  ward,  its  point 
may  be  driven  through  the  skin  and  "version"  accomplished  and  the 
head  brought  out  through  the  meatus  (Figs.  300,  301). 


404  FOREIGN   BODIES. 

In  other  cases  it  may  be  necessary  to  do  an  external  urethrotomy, 
and  finally  the  object  may  have  to  be  pushed  into  the  bladder  and 
removed  by  suprapubic  cystotomy. 

Hazzard  describes  a  case  in  which  a  hat  pin  was  lodged  in  the  urethra, 
its  head  too  high  to  manipulate.  He  bent  the  penis  at  a  right  angle  to 
the  direction  of  the  pin  and  thus  thrust  its  point  through  the  skin,  which 
enabled  him  to  practice  version  (J.  A.  M.  A.,  May  29,  1909). 

Hyde,  of  Kansas  City,  reports  a  shawl  pin  slipped,  head  first,  down 
the  urethra  and  into  the  bladder.  The  point  could  be  felt  at  the  peno- 
scrotal angle.  An  incision  was  made  down  to  the  urethra,  the  point 
was  forced  through  the  urethral  wall  into  the  incision,  and  the  pin 
drawn  out  till  the  head  reached  the  urethral  floor;  it  was  then  reversed 
and  delivered  through  the  meatus  without  opening  the  urethra.  The 
wound  was  closed  by  three  deeply  placed  silkworm-gut  sutures  with 
prompt  repair  (J.  A.  M.  A.,  March  13,  1909). 


CHAPTER  XX11. 
BURNS,  SCALDS,  AND  FROSTBITE. 

From  the  point  of  view  of  prognosis  and  treatment,  burns  are  of 
three  degrees: 

(i)  Transient  application  of  heat,  something  below  the  boiling- 
point,  produces  hyperemia. 

(2)  A  greater  degree  of  heat  or  a  longer  application  produces  a 
more  definite  vaso-motor  paralysis  and  there  is  exudation,  particularly 
into  the  Malphighian  layer,  and  the  epidermis  is  lifted  up  in  the  form 
of  blisters. 

(3)  The  albumen  of  the  tissues  and  fluids  is  coagulated.  This 
necrobiosis  may  be  superficial  or  it  may  involve  the  deep  structures 
as  well. 

Symptoms. — Even  in  slight  burns,  pain  is  always  a  prominent 
symptom.  In  the  severer  burns,  shock  is  always  present  in  some 
degree,  and  as  the  shock  disappears,  reaction  comes  on,  with  rise  of 
temperature,  and  the  symptoms  resolve  themselves  into  some  form 
of  internal  congestion,  or  systemic  intoxication,  characterized  by 
hemoglobinuria  or  albuminuria,  vomiting,  or  bloody  diarrhea.  After 
a  few  days  the  symptoms  may  be  those  of  septic  infection. 

The  cause  of  death  from  burns  falls  into  four  groups: 

(a)  Shock.  This  may  be  rapidly  fatal,  sometimes  as  late  as  twenty- 
four  hours.  Death  may  be  due  to  cardiac  paralysis,  the  result  of  over- 
heating of  the  blood. 

(b)  Toxemia.  The  tox-albumens  resulting  from  the  chemical 
changes  in  the  tissues  find  their  way  into  the  circulation  and  over- 
whelm the  heart  and  kidneys,  usually  within  the  first  two  or  three 
days.  It  has  been  demonstrated  that  these  toxic  substances  arc 
hemolytic  and  cytotoxic  for  the  parenchyma  cells  and  are  eliminated 
from  the  body  by  the  kidneys  and  intestinal  tract. 

405 


406  BURNS,    SCALDS  AND   FROSTBITES. 

(c)  Internal  congestion  and  inflammation,  involving  the  cerebral, 
thoracic,  or  abdominal  structures. 

(d)  Septic  infection  or  its  sequela.  This  may  be  fatal  after  the  first 
few  days  or  only  after  a  prolonged  struggle. 

Factors  Determining  the  Prognosis. — (a)  Area  and  depth  of  burn. 

(b)  Age  and  general  condition  of  patient. 

(c)  Region. 

(d)  Degree  of  infection. 

The  rules  for  determining  the  prognosis  can  be  formulated  only 
in  a  general  way  with  reference  to  these  various  factors,  and  yet  keep- 
ing them  in  mind,  a  quite  definite  forecast  may  often  be  made  in  a 
given  case. 

(a)  It  is  the  area  rather  than  the  depth  of  the  burn  which  deter- 
mines the  danger.  An  extensive  superficial  burn  is  more  dangerous 
than  a  limited  but  deep  one.  It  appears  that  under  the  effect  of  heat 
muscular  tissue  generates  a  poison  much  less  toxic  than  that  from 
the  skin.  Mere  reddening  of  two-thirds  of  the  cutaneous  surface 
will  almost  inevitably  result  in  death,  while  destruction  of  one-third 
of  the  skin  will  probably  produce  the  same  result,  yet  most  burns  of 
the  first  and  second  class  commonly  met  in  practice  will  recover. 

(b)  The  age  and  general  condition  involve  the  question  of  the 
ability  to  rally  from  shock  and  to  resist  infection.  By  reason  of  their 
lack  of  resistance  to  these  forces,  the  young  or  the  aged  may  succumb 
to  even  slight  burns  of  the  third  degree. 

fc)  Burns  over  the  head  are  dangerous  for  the  reason  that  menin- 
gitis may  develop,  and  similarly  burns  of  the  thorax  and  abdomen  are 
likely  to  result  in  lesions  of  their  contained  viscera.  Burns  about  the 
face  are  often  accompanied  by  corresponding  injury  to  the  air  passages 
by  inhalation  of  smoke  or  flames. 

(d)  The  most  important  factor,  however,  in  the  process  of  severe 
burns  is  infection.  Such  injuries,  in  fact,  are  infected  wounds.  The 
coagulated  albumens  of  the  destroyed  tissues  are  not  favorable  soil 
for  the  development  of  the  bacteria,  but  around  the  circumference  of 
the  burn  are  tissues  of  lowered  vitality  which  are  not  only  unable  to 
resist  the  encroaching  germ,  but,  more  than  that,  actually  nourish  it. 

The  serous  exudates  of  superficial  burns  are  likewise  culture  media, 


TKl  \  I  \li  N  l    01    BURNS.  407 

Id  thai  in  severe  burns  as  well  as  in  other  wounds  it  may  be  said  thai 
the  patient's  fate  lies  in  the  tir>t  dressing. 

Treatment.-  Slight  burns  of  the  first  degree  require  protection, 
which  may  be  furnished  by  vaseline;  by  gauze  saturated  in  boracic 
ai  id  solution;  by  canon  oil;  by  dusting  powders  of  various  kinds, 
boracic  acid,  dermatol,  bicarbonate  of  soda,  Hour. 

///  severe  burns  the  indications  are  to  combat  the  shock,  to  relieve 
the  pain,  and  to  prevent  infection.  In  the  matter  of  the  local  treat 
pent  of  these  conditions, the  final  word  has  not  yet  been  spoken.  The 
most  divergent  opinions  appear  in  current  literature,  and  of  these 
various  lines  of  treatment  perhaps  none  are  wholly  bad  certainly,  few 
are  altogether  good. 

Begin,  then,  by  combating  shock  and  relieving  pain.  These  two 
conditions  are  usually  relieved  at  once  by  frequent  but  small  hypo- 
dermic doses  of  morphia,  supplemented  by  subcutaneous  or  venous 
injections  of  salt  solutions.  If  parts  beneath  the  clothing  are  involved, 
use  the  greatest  care  in  removing  so  that  the  skin  will  not  be  removed 
with  it. 

To  cut  the  clothing  is  safer  than  to  attempt  to  undress  the  patient. 
Always  remember  that  contact  with  the  clothing  may  be  the  chief 
source  of  infection. 

Now,  what  will  one  do  to  prevent  infection?  This  is  the  chief 
problem. 

If  the  burn  is  of  large  extent  and  depth  as  well  and  has  been  in 
contact  manifestly  with  sources  of  infection,  there  is  but  one  thing 
to  do  if  the  aseptic  method  is  to  be  employed.  Anesthetize  the  patient 
after  the  shock  has  passed  and  proceed  to  sterilize  the  parts.  Scrub 
the  uninjured  skin  around  the  wound  with  soap  and  water  and  then 
alcohol  and  bichloride.  Next  proceed  to  irrigate  the  burned  area 
with  normal  salt  solution,  in  the  meantime  carefully  rubbing  with 
sterile  gauze  to  the  end  that  every  bit  of  foreign  matter  may  be  removed. 
In  those  parts  that  are  merely  blistered,  the  blebs  are  to  be  punctured 
and  the  serum  washed  away.  It  may  be  advisable,  even,  for  the  sake 
of  thorough  disinfection,  to  make  no  effort  to  spare  the  cuticle  of  the 
blisters  in  rubbing  with  the  sterile  gauze. 

.Not  hurriedly,  bu1  patiently  complete  this  cleansing.     It  will  prob 


408  BURNS,    SCALDS  AND   FROSTBITES. 

ably  require  from  one-half  to  three-quarters  of  an  hour,  but  it  is  time 
well  spent.     You  have  now  now  to  deal  with  an  aseptic  wound. 

Next  cover  the  area  with  plain  sterilized  or  borated  gauze  and  over 
this  apply  absorbent  cotton  and  bandage  snugly. 

If  much  cuticle  has  been  removed,  cover  with  sterile  vaseline  before 
applying  the  sterile  gauze. 

The  aid  of  a  splint  may  be  required  to  prevent  deformity.  If  no 
fever  arises  the  dressing  need  not  be  changed  for  eight  or  ten  days. 

It  may  not  be  practical  to  institute  the  thorough  disinfection  which 
anesthesia  alone  permits,  but  one  can  at  least  cleanse  the  adjacent 
area  as  before  described.  Prick  the  blisters  and  irrigate  the  burnt 
area  with  normal  salt  solution,  but  in  this  case  sterilization  is  not  so 
much  a  certainty. 

Therefore,  you  must  employ  an  antiseptic  dressing.  Whatever 
dressing  you  select  should  have  these  properties  at  least;  it  should  be 
antiseptic,  analgesic,  and  keratogenic.  A  number  of  substances  possess 
these  properties  in  various  degrees  and  are  otherwise  more  or  less 
unobjectionable. 

Picric  Acid. — This  is  employed  in  solutions  of  x  or  2  per  cent.  A 
good  solution  is  made  by  dissolving  one  and  one-half  drachms  in  three 
ounces  of  alcohol  and  adding  some  of  this  solution  to  two  parts  of 
water.  After  cleansing  the  surface  apply  strips  of  sterile  gauze, 
soaked  in  the  solution,  cover  with  absorbent  cotton  and  bandage. 
Change  the  dressing  in  three  to  four  days,  soaking  it  loose  with  the 
same  solution. 

Turpentine. — This  is  an  excellent  domestic  remedy,  antiseptic  and 
analgesic,  but  only  to  be  employed  in  slight  burns  of  the  first  degree. 
Cover  the  area  with  absorbent  cotton  and  saturate  with  the  turpentine, 
and  bandage. 

;4mto/.— This,  too,  renders  excellent  service.  Use  as  an  ointment 
mixed  with  sterile  vaseline  or  zinc  ointment  in  the  proportion  of  eight 
to  ten  grains  to  the  ounce  and  apply  spread  on  sterile  gauze. 

The  Ointment  cf  Rectus. — This,  perhaps  better  than  any  other 
ointment,  meets  all  the  indications.  It  is  applied  in  a  thin  layer 
directly  to  the  surface  or  spread  on  sterile  gauze  and  the  dressing  com- 
pleted with  cotton  and  bandage.     Here  is  the  formula  of  the  ointment 


BURNS    OF    THE    MOUTH.  }0<> 

as  modified  by  the  author  and  prepared  by  the  Pitman,  Myers  Co., 
and  which  should  be  ready  lor  instant  use: 


; — Hydrarg.  Chlor.  Corros., 

i  part. 

At  i.l  t larbol., 

30  parts, 

Aristol, 

3° 

Acid  Boric, 

90     ' 

Salol, 

go     ' 

Anti]>yrine, 

150     ' 

Petrolatum, 

576     ' 

Carron  Oil. — This  is  an  old  and  useful  remedy,  but,  as  ordinarily 
used,  unqualifiedly  to  be  condemned.  It  favors  suppuration  because 
it  is  in  nowise  antiseptic  and  perhaps  may — indeed  often  does — carry 
infection.  If  the  oil  is  sterilized  and  then  applied  to  the  surface  which 
has  been  made  as  clean  as  possible,  it  is  an  efficient  dressing. 

Granger,  of  Rochester,  Minn.,  uses  equal  parts  of  lanolin  and  zinc 
ointment  spread  thickly  on  gauze,  covering  the  ointment  with  the 
waxed  paper  sold  by  instrument  dealers,  and  applying  the  dressing 
with  the  paper  next  to  the  burned  surface.  The  dressing  is  next 
covered  with  a  thin  layer  of  cotton.  He  claims  that  it  is  soothing  and 
easily  removed. 

The  frequency  with  which  any  dressing  must  be  changed  will  depend 
on  the  pain  or  infection.  If  the  secretions  are  excessive  and,  by  dry- 
ing and  stiffening  the  dressing,  aggravate  the  pain,  the  dressings  must 
be  frequently  changed. 

If  there  is  infection,  the  rise  of  temperature  will  be  the  index.  The 
same  care  must  be  exercised  in  changing  the  dressings  as  in  treating 
any  other  wound. 

BURNS  OF  THE  MOUTH. 

Burns  of  the  mouth  and  air  passages  are  not  infrequent.  These 
may  be  the  result  of  taking  hot  substances  into  the  mouth  or  the 
inhalation  of  hot  gases  in  explosions.  Pain  and  difficulty  in  swallow- 
ing are  the  most  frequent  symptoms.  In  addition  there  may  be  edema 
of  the  glottis  or  finally  acute  bronchitis  may  develop.  Cold  water  and 
bits  of  ice  give  the  most  relief.  The  edema  of  the  glottis  may  require 
tracheotomy.  The  various  forms  of  inflammation,  such  as  bronchitis 
or  pneumonia,  must  be  treated  on  general  principles. 


4IO  BURNS,    SCALDS   AND    FROSTBITES. 

ELECTRICAL    BURNS   AND    SHOCKS. 

Electrical  burns  are  painful  out  of  all  proportion  to  the  size  of  the 
lesion  and  require  two  or  three  times  as  long  as  the  ordinary  burn  for 
repair. 

Begin  the  treatment  with  hypodermics  of  morphia  and  strychnia 
(1/30).  Cleanse  the  wound  by  the  ordinary  surgical  methods  and 
dress  with  sterile  gauze,  cotton,  and  bandage. 

The  resuscitation  of  persons  shocked  by  electricity  is  necessitated 
much  more  often  than  formerly  by  reason  of  the  widespread  use  of 
the  electric  current.  Spitzka  has  lately  outlined  the  course  to  pursue 
in  the  treatment  of  such  cases.  He  remarks,  in  the  first  place,  that  one 
cannot  safely  predict  exactly  what  will  happen  in  any  case  of  shock 
by  electricity,  for  many  factors  modify  the  action  of  the  current: 
its  nature,  tension,  intensity;  the  resistance  and  susceptibility  of  the 
individual;  the  duration,  location,  and  area  of  contact.  Broadly 
stated,  the  effect  is  the  more  severe,  the  greater  the  voltage,  the  greater 
the  amperage,  the  longer  the  period  of  contact,  the  greater  the  area 
of  contact,  and  the  longer  the  path  of  the  current  through  the  body. 

Death  by  electrical  contact  would  appear  to  be  due  to  heart  paraly- 
sis or  to  asphyxia,  or  a  combination  of  both.  In  certain  cases  there 
is  no  paralysis  of  the  heart,  but  only  respiratory  failure. 

The  symptoms  of  electrical  shock  in  cases  which  are  not  immedi- 
ately fatal,  vary  greatly  in  form  and  degree. 

I.  Local  signs: 

(a)  Burns  and  superficial  necroses. 

(b)  Puncture  and  rupture  of  tissues. 

(c)  Hemorrhages. 

(d)  Edema  and  erythemas. 

II.  General  effects: 

(a)  Loss  of  consciousness. 

(b)  Paralysis  and  spasms  of  muscles. 

(c)  Disturbances  of  respiration  and  circulation. 

(d)  High  temperature. 

Later  there  may  develop  disturbances  of  the  bowels,  kidneys,  special 
sense  organs,  the  central  and  peripheral  nervous  system. 


FK  I  AIM  i   \  I     OF     IK  I   I  VIM..  41  I 

The  prognosis  is  good  only  in  cases  where  there  is  some  hear!  tu  tion 
and  respiration  and  where  treatment  can  be  promptly  applied. 

Treatment:     If  the  stricken  man  is  not  out  of  the  circuit,  some  1  au 
tion  must  be  exercised  in  accomplishing  his  relief.    The  rescuer  should 

have  on  rubber  gloves  or  have  his  hands  wrapped  in  thick,  dry,  woolen 
material,  to  avoid  shock  from  handling  the  victim.  He  may  be  freed 
by  pulling  at  his  clothing  or  using  sticks  of  wood.  If  it  is  necessary  to 
cut  a  wire,  the  nippers  must  have  insulated  handles  and  the  eyes 
should  be  protected  from  the  blinding  Hash. 

Once  freed,  the  patient  should  be  laid  with  head  elevated  and  arti- 
ficial respiration  at  once  begun.  This  is  more  effectively  done  by 
compressing  the  chest  with  the  hands  applied  flat  against  the  sides  of 
the  lower  part  of  the  thorax.  The  tongue  must  be  drawn  forward  so 
as  not  to  obstruct  the  larynx.  Massage  over  the  heart  and  faradism 
help  to  stimulate  its  action.  Arterial  infusion  of  adrenalin  has  been 
proven  by  Crile  and  Dolly  to  have  a  direct  effect. 

Other  methods  which  have  been  suggested  are  lumbar  puncture, 
venesection,  and  the  high-tension  shock  of  short  duration  (Jour. 
Med.  Soc.  New  Jersey,  Jan.,  1909). 

FREEZING. 

The  effects  of  very  low  temperature  on  the  tissues  are  practically 
the  same  as  those  of  heat.  The  ultimate  effect  is  death  of  the  tissues 
or  gangrene. 

The  treatment  of  patients  overcome  by  cold  must  be  circumspect. 
The  main  point  is  to  go  slow  in  warming  the  parts.  The  patient 
should  never  be  brought  directly  from  outdoors  into  a  warm  room. 
Sonnenburg  advises  that  a  cold  bath,  the  temperature  of  the  cold  room, 
be  used,  and  the  temperature  gradually  raised  until  in  two  or  three 
hours  it  reaches  8o°  F.  Where  life  seems  extinct,  artificial  respi- 
ration should  be  practised,  and  sometimes  the  circulation  may  thus 
be  re-established.  Subsequently  hot  rectal  enemata  of  whiskey  or 
coffee  may  be  employed.  The  limbs  and  other  frozen  parts  should 
be  covered  with  moist  compresses  for  the  first  forty-eight  hours  and 
then  dusted   with   boracic  acid  and  encased   in  a  thin  layer  of  wool. 


412  BURNS,    SCALDS   AND    FROSTBITES. 

If  the  trouble  is  only  local — a  frozen  ear  or  foot — begin  by  rubbing 
the  part  with  snow  or  ice  and  then  with  cold  water  and  finally  apply 
cold  compresses,  gradually  raising  their  temperature  until  the  circu- 
lation is  restored.  Subsequently  cooling  lotions  may  be  employed 
to  allay  the  inflammation. 


PART  11. 


CHAPTER  I. 


TRACHEOTOMY,  LARYNGOTOMY,  ESOPHAGOTOMY. 


Tracheotomy  is  often  performed  in  general  practice  as  an  operation 
of  the  greatest  urgency,  and  one  should  be  prepared  to  do  it  anywhere, 
at  any  time,  and,  if  necessary,  with  a  pen-knife.  Yet  it  is  not  so  simple 
a  procedure  as  one  might  infer.  To  do  it  properly  and  quickly,  re- 
quires coolness  knowledge,  and  method.  It  is 
the  measure  of  relief  indicated  in  every  case  of 
laryngeal  asphyxia,  whether  due  to  spasm  of  the 
larvnx,  edema  following  burns,  injuries,  or  disease 
such  as  diphtheria  or  cancer;  or  to  the  presence 
of  foreign  bodies.  The  essential  equipment  is  a 
sharp  pointed  scalpel  and  a  tracheotomy  tube, 
and  to  these,  as  mere  conveniences,  may  be  added 
scissors,  artery  and  dissecting  forceps,  tenacula, 
mouth-gag,  and  tongue  forceps. 

The  tracheotomy  tube  (Fig.  302)  should  be  of 
simple  construction,  easy  to  introduce,  and  as 
large  as  the  diameter  of  the  trachea  will  admit, 
following  table  relative  to  the  age  of  the  patient  and  the  diameter  of 
the  tube: 


Fig.  302. — Tracheotomy 
tube. 


Treves  furnishes  the 


AGE. 

Under  18  months, 
1 J  to  2  years, 
2  to  4  years, 
4  to  8  years, 
8  to  12  years, 
12  to  15  years, 
Adults, 


DIAMETER   OF   THE   TUBE. 

4  mm. 

5  mm. 

6  mm. 
8  mm. 

1  o  mm. 
12  mm. 
1  2  to  1  5  mm. 


413 


414 


TRACHEOTOMY,    LARYNGOTOMY,    ESOPHAGOTOMY. 


Every  practitioner  should  have  tubes  of   various  sizes  in  his  "ar 
senal";  Senn  recommends  Trosseau's,  while  Lejars  prefers  those  of 
Krishaber. 

Anesthesia  is  often  unnecessary,  owing  to  the  condition  of  the  patient. 
Otherwise  a  few  whiffs  of  chloroform  should  suffice.  It  need  scarcely 
be  said  that  under  these  circumstances,  free  use  of  the  anesthetic  will 
only  hasten  the  fatality. 

The  preparation  of  the  field,  however  desirable,  the  urgency  of  the 
symptoms  will  scarcely  permit. 


Fig.  303. — Locating  the  cricoid  cartilage. 


The  little  patient's  arms  should  be  pinioned  to  its  sides  with  a  towel 
or  sheet,  it  should  be  placed  on  its  back  with  a  cushion  under  its 
shoulders  to  drop  the  head  backward  and  bring  the  trachea  into  bolder 
relief. 

Operation. — Stand  at  the  right  side  of  the  patient;  locate  the  hyoid 
bone,  the  thyroid  prominence,  the  cricoid  cartilage,'  and  the  sternal 
notch;  and  steady  the  trachea,  holding  the  cricoid  between  the  middle 
finger  and  the  thumb  of  the  left  hand,  while  the  index  finger  locates 
the  middle  line  (Fig.  303). 

It  is  along  the  middle  line  that  one  must  incise,  and  the  aim  is  to 


OP]  R  \  I  [ON  FOB  ik  M  in  nin\n 


415 


divide  the  upper  rings  of  the  trachea  and  to  avoid  the  thyroid  isthmus 

(Fig.  3°4). 

Make  the  incision  from  the  index  finger  downward  exactly  in  the 
middle  line  for  two  inches  (Fig.  305).  Incise  rapidly  with  a  single 
sweep  of  the  knife.  The  left  index-finger  in  the  upper  angle  of  Un- 
wound hooks  up  the  cricoid  and  still  locates  the  middle  line.  Pay 
no  attention  to  the  bleeding,  and  without  hesitation  push  the  point 
of  the  bistoury  through  the  upper  ring  and  cut  downward  through  the 
second  and  third  if  necessary.  The  air  hisses  through  the  opening. 
It  is  a  moment  of  confusion,  but  one  must  keep  cool. 

Insert  the  lube.  Without  changing  its  position, 
the  left  index  finger  presses  the  tracheal  wound 
open  and  the  right  hand  introduces  the  tube, 
horizontally  at  first,  until  the  point  is  well  in  the 
trachea,  and  then  carries  the  tube  upward  in  a 
Curve  until  its  break  corresponds  to  the  lumen  of 
the  trachea  (Fig.  306).  The  patient's  gasps  expel 
blood  and  perhaps  false  membrane,  which  the 
attendants  must  avoid  inhaling.  The  tapes  at- 
tached to  the  tube  are  fastened  behind  the  neck. 
Apply  artificial  respiration  if  the  patient's  condi- 
tion is  not  satisfactory.  Let  the  air  pass  through  FlG 
a  warm,  moist  compress  until  the  temperature  of  represent3  the^thvruiii 
tin   room  can  be  regulated.  isthmus.    (Veau.) 

As  Veau  points  out,  the  operation  may  fail  for 
Several  reasons,  all  within  the  control  of  the  operator.  The  most 
frequent  cause  of  failure  is  faulty  introduction  of  the  tube;  it  does  not 
enter  the  tracheal  canal,  but  is  pushed  down  between  the  mucous 
membrane  and  the  tracheal  wall.  These  structures  are  loosely  con- 
nected. The  error  is  to  be  recognized  by  the  absence  of  the  charac- 
teristic sound  of  escaping  air. 

The  orifice  is  to  be  inspected, and,  if  too  small,  enlarged,  before  trying 
the  second  time  to  introduce  the  tube. 

Again,  too  much  force  in  making  the  incision  may  result  in  wounding 
the  posterior  wall  of  the  trachea.  Excited  operators  have  split  the 
trachea  its  entire  length,  or  wounded  the  vessels  of  the  neck.     There 


-Tracheo- 


416  TRACHEOTOMY,    LARYNGOTOMY,    ESOPHAGOTOMY. 


Fig.    305. — Tracheotomy.     Incision.     (Veau.) 


Fig.  306. — Introducing  the  tracheotomy  tube.     (Veau.) 


TRACHEOTOME     FOK    roREICN     l'.«-DHS.  |  i  7 

need  be  but  little  hemorrhage  in  the  operation,  if  one  but  keeps  in  the 
middle  line;  and,  as  Senn  says,  that  is  the  se<  ret  of  success  in  performing 
the  operation  quickly  and  safely. 

The  operation  may  be  varied  somewhat,  depending,  of  course,  upon 
the  conditions.  The  cricoid  may  be  divided  if  necessary.  In  other 
Rises,  before  cutting  downward  it  may  be  ne<  essary  to  draw  downward 
the  isthmus  of  the  thyroid  gland  before  enlarging  the  opening. 

In  any  case  where  time  does  not  press,  as  when  the  tracheotomy  is 
done  preliminary  to  some  other  operation,  the  various  steps  may  be 
carried  out  with  more  detail,  the  incision  made  by  layers,  vessels 
clamped,  and  the  rings  exposed,  steadied  with  hoods,  and  incised. 

The  tracheotomy  may  be  done  below  the  isthmus  of  the  thyroid, 
but  the  higher  operation  is  much  the  easier  anatomically,  although 
the  principle  is  the  same. 

Tracheotomy  for  foreign  bodies  differs  in  some  respects  from  the 
ordinary  technic.  Westmoreland,  of  Atlanta,  who  has  had  a  large 
experience  with  this  class  of  cases  has  recently  emphasized  some  of 
these  points  (Amer.  Jour,  of  Surg.,  Nov.,  1909). 

The  incision  should  vary  in  length  depending  upon  the  size  and 
character  of  the  foreign  body.  If  the  opening  is  sufficiently  large  the 
foreign  body  is  easily  expelled  by  the  respiratory  effort;  usually  the 
opening  is  made  too  small  and  the  trachea  is  injured  by  the  forcible 
extraction  of  the  body.  In  the  young  the  thyroid  isthmus  is  usually 
in  the  way  ami  should  be  divided  between  forceps  and  ligated.  Even 
the  thymus  gland  may  intrude  and  is  to  be  depressed  with  a  narrow 
retractor,  A  tenaculum  should  not  be  employed  lest  it  excite  a 
troublesome  bleeding. 

The  incision  in  the  trachea  itself  begins  at  the  first  ring.  If 
asphyxia  should  occur  in  the  course  of  the  operation,  the  result  of 
fixation  of  the  objeel  in  the  glottis,  the  operation  should  be  rapidly 
finished,  a  tube  or  catheter  passed  into  the  trachea  and  the  lung  in- 
flated by  blowing  through  the  tube — a  great  help  in  artificial  respira- 
tion which  soon  resuscitates  the  asphyxiated  child. 

Tracheotomy  lubes  are  not  to  be  used.  Once  the  trachea  is  opened 
the  body  may  be  coughed  out  which  a  lube  would  prevent.  The 
27 


41 8  TRACHEOTOMY,    LARYNGOTOMY,    ESOPHAGOTOMY. 

wound  may  be  held  open  if  necessary  by  silk  threads  passed  through 
its  edges. 

If  the  foreign  body  is  expelled  the  trachea  is  to  be  sutured  at  once, 
employing  a  mattress  suture  of  silk  which  is  not  to  pass  through  the 
mucous  membrane.  Whether  the  tracheal  wound  is  made  air-tight 
or  not  is  to  be  tested  by  filling  the  wound  with'  normal  salt  solution 
and  obstructing  the  nose  and  mouth  which  will  force  some  bubbles 
through  if  not  tight.  The  fascia,  muscles  and  isthmus,  and  finally 
the  skin  are  repaired.  The  dressing  is  held  in  place  by  adhesive 
strips. 

If  inflammation  exists,  even  though  the  body  is  expelled,  do  no 
suturing;  cover  the  wound  loosely  with  bichloride  gauze  to  keep  out 
cold  air  and  to  absorb  the  discharges.     Change  frequently 

//  the  foreign  body  is  not  expelled  the  protective  dressing  is  to  be 
applied  which  will  not  prevent  the  escape  of  the  object  if  it  should 
be  coughed  up  later,  and  under  this  treatment  the  inflammation  will 
probably  rapidly  subside. 

After-treatment. — The  success  of  tracheotomy  rests  largely  on  the 
care  with  which  the  after-treatment  is  conducted.  There  is  no  opera- 
tion, perhaps,  in  which  care  and  skill  are  better  rewarded  and  negligence 
and  ignorance  more  severely  punished.  If  the  temperature  of  the 
room  cannot  be  kept  at  close  to  650,  the  tube  should  be  kept  covered 
with  a  warm,  moist  compress.  The  wound  must  be  kept  clean.  For 
the  first  few  days,  the  inner  tube  must  be  removed  and  cleansed  several 
times  daily.  This  should  be  done  rapidly,  and  the  tube  disinfected  and 
oiled  before  being  reintroduced. 

Morse  (Post-operative  Treatment,  page  174)  says,  unless  the  cause 
of  obstruction  is  a  permanent  one,  it  is  often  advisable  to  remove  the 
tube  after  twenty-four  to  forty-eight  hours;  but  the  patient  should  be 
allowed  to  try  breathing  through  the  mouth  before  removing  the  tube, 
testing  his  capacity  by  stopping  the  cannula.  In  any  event,  he  should 
be  gradually  accustomed  to  breathing  through  the  mouth  by  plugging 
the  canula. 

Morse  advised  that  soup,  milk,  or  broth  should  be  given  at  first, 
if  necessary  through  a  nasal  or  esophageal  tube,  although  this  is  not 
often  required.     Difficulty  in  swallowing  is  likely  to  occur  on  the  third 


0P1  RATION    I  OB    ik  \<  in  OTOMY.  \  m 

»>r  fourth  day,  l>ut  encouragement  will  enable  the  patient  to  overcome 
this.     Nutrient  enemas  art-  rare  I)  necessary. 

Link,  of  [ndianapolis,  relates  an  experience  (Medical  Record, 
March  2,  1907)  which  illustrates  at  once  the  value  of  the  operation, 
the  improvizatioD  of  instruments  to  meet  an  emergency,  and  one  of 
the  rarer  forms  of  suffot  ating  edema. 

At  midnight  he  was  tailed  to  see  a  patient  said  io  be  choking  to 
death  and  whom  he  supposed  had  an  attack  of  asthma.  lie  found 
the  patient,  a  man  weighing  250  pounds,  cyanosed  and  laboring  for 
breath.  One  hour  previously,  it  seems,  his  throat  had  been  lanced 
for  the  eleventh  time  in  the  course  of  a  ten  days'  attack  of  tonsillitis. 

A  hurried  examination  found  the  pharynx  too  tightly  swollen  to 
pass  a  finger.  How  much  laryngeal  edema  there  might  be  could  only 
be  guessed.  Thinking  to  intubate  past  the  swollen  pharynx,  Link 
used  the  only  thing  available,  the  vaginal  tip  from  a  hard  rubber 
syringe,  bent  at  nearly  a  right  angle.  The  attempt  failed.  While 
preparing  for  a  local  anesthesia  to  do  a  tracheotomy,  the  patient's 
neck  was  surrounded  with  iced  cloths,  but  this  seemed  to  aggravate 
the  asphyxia;  the  patient  became  unconscious  and  ceased  to  breathe. 

The  anesthesia  was  no  longer  necessary.  All  had  fled  but  one 
woman,  and  while  she  held  the  patient's  head,  the  doctor  did  a  low 
tracheotomy. 

He  says,  kneeling  in  front  of  the  patient,  who  was  in  a  sitting  posture, 
he  incised  the  skin  and  deep  fascia  in  the  median  line  two  inches 
above  the  sternal  notch,  working  with  his  finger  down  to  the  bronchial 
rings.  With  the  finger  as  a  guide,  the  knife  was  introduced,  the 
trachea  stabbed  and  cut  slightly  upward.  A  closed  hemostat  was  then 
introduced  and  opened.  Very  little  blood  was  lost.  A  female  silver 
catheter  from  his  pocket  case  was  introduced  and  held  in  place  by  the 
assistant,  while  the  doctor  performed  artificial  respiration. 

The  patient  soon  began  to  breathe,  but  his  convulsive  movements 
threatened  the  loss  of  the  small  tube  in  the  throat.  The  hard-rubber 
vaginal  syringe  tip  was  brought  into  use  again,  whittled  and  inserted. 
Tin-  elbow  shape  fitted  perfectly.  In  half  an  hour  the  patient  asked 
to  be  put   to  bed,  and  breathing  entirely  through  the  tube,  slept  the 

Brsl  sleep  for  several  nights. 


420 


TRACHEOTOMY,    LARYNGOTOMY,    ESOPHAGOTOMY. 


The  edema  declined  as  fast  as  it  had  arisen,  and,  within  a  few  hours, 
the  patient  could  breathe  through  the  mouth  when  the  tube  was 
closed,  and  recovery  was  uneventful. 

LARYNGOTOMY. 

As  an  emergency  operation,  this  is  most  frequently  done  in  an  adult 
for  cancer,  but  one  need  not  wait  until  the  patient  is  asphyxiated  for 
there  is  nothing  gained  thereby.  Therefore  one  may  operate  deliber- 
ately, for  there  is  not  the  extreme  urgency  as  with  the  infant. 

Local  anesthesia  may  be  sufficient.  Define 
as  before  the  inferior  border  of  the  thyroid 
cartilage  and  the  upper  border  of  the  cricoid, 
between  which  is  the  crico-thyroid  membrane 
which  is  to  be  incised  (Fig.  307).  In  the 
middle  line  over  the  space,  make  a  vertical 
incision  an  inch  long.  Catch  the  bleeding 
points  and  retract  the  lips  of  the  wound. 
Carefully  incise  the  fascia  until  these  cartilages 
are  exposed.  Now  incise  the  crico-thyroid 
membrane  transversely  and  open  into  the 
larynx  (Fig.  308). 

Introduce  the  tube  as  in  tracheotomy.     Re- 
move and  cleanse  the  inner  tube  on  the  first 
two  days  and  the  large  tube  on  the  third  day. 

Of  course,  if  the  operation  is  for  cancer,  it  is  merely  palliative  and  the 
patient  will  continue  slowly  to  die.  If  the  operation  is  for  edema  of  the 
larynx,  the  cause  must  be  treated  and  the  proper  time  finally  to  with- 
draw the  tube  determined  by  the  conditions.  If  the  operation  is  for  a 
foreign  body,  the  wound  may  be  sutured  at  once. 


Fig.  307. — Laryngotomy. 
Incision  of  crico-thyroid 
membrane.      (Veau.) 


ESOPHAGOTOMY  (Cervical  Region). 

Position. — Place  the  patient  on  his  back  with  shoulders  elevated 
and  the  neck  resting  on  a  sand-bag  with  head  turned  to  the  right. 

Incision. — Begin  opposite  the  upper  border  of  the  thyroid  cartilage 
and  continue  downward  along  the  anterior  border  of  the  left  sterno- 


«>l-i  km  |. in    i  OH    l  SOPHAGOTOMY. 


.).'  i 


mastoid  for  three  or  four  inches,  incising  the  skin,  superficial  fascia, 
and  platysma.     Ligate  the  veins  and  draw  the  sterno  mastoid  forward 

and  the  depressors  of  the  byoid  downward.  The  wound  is  thus 
enlarged  and  at  the  bottom  is  the  layer  of  cervical  fascia  connecting 
the  thyroid  gland  and  the  sheath  of  the  large  vessels.  Incise  it  and 
again  enlarge  the  wound  by  drawing  forward  the  thyroid  gland, 
trachea,  and  larynx,  and  backward,  the  greal  vessels  in  their  sheaths. 
At  this  stage,  in  the  bottom  of  the  wound  are  the  inferior  thyroid. 


Fig.  308.— Laryngotomy.      Incision  of  the  crico-thyroid  membrane.     (Veau.) 


which  must  be  ligated,  and  the  recurrent  laryngeal  nerve,  which  should 
he  drawn  forward. 

The  esophagus  now  appears  as  a  red  tube.  To  steady  the  esoph- 
agus and  define  iis  walls,  an  esophageal  bougie  may  be  inserted.  The 
wall  of  the  esophagus  is  raised  with  mouse-tooth  forceps  (Fig.  309) 
and  incised  along  its  lateral  wall.  A  suture  is  passed  through  each 
li]>  of  the  inri^ion,  that  they  may  he  readily  retracted  while  the  foreign 
body  i>  located  and  removed,  not  always  the  easiest  part  of  the  task. 

The  wound  of  the  esophagus  is  repaired  with  sutures  of  catgut  and 


422 


TRACHEOTOMY,    LARYNGOTOMY,    ESOPHAGOTOMY. 


the  rest  of  the  wound  lightly  packed  with  gauze  until  all  danger  of  in- 
fection is  passed. 

As  Bryant  says,  ordinarily  the  operation  of  cervical  esophagotomy 
is  not  a  perplexing  procedure,  but  when  the  neck  is  short  and  fat,  the 
vessels  and  thyroid  gland  enlarged,  the  detection  and  removal  of  the 
foreign  body  difficult,  or  the  patient  exhausted,  the  operation  often 
taxes  the  patience  and  fortitude  of  the  surgeon. 

After-treatment.— The  patient  must  be  kept  in 
bed  with  shoulders  raised.  Nourishment  should 
be  given  at  first  by  enemata,  and  later,  if  neces- 
sary, by  the  esophageal  tube. 

Nassau  reports  a  case  illustrating  the  subject 
(Annals  of  Surgery,  Feb.,  1908).  A  child 
swallowed  a  five-cent  piece  and  thereafter  could 
take  only  liquid  foods.  " X-ray"  examination 
showed  the  coin  lodged  at  the  level  of  the 
suprasternal  notch  or  just  above. 

Removal  was  attempted  with  forceps  but 
without  success,  although  the  coin  could  be  felt. 
An  esophagotomy  was  done.  The  operation 
was  completed  in  fourteen  minutes.  No  vessels  require  ligation. 
The  esophagus  was  not  sutured  and  the  superficial  wound  was  closed 
with  drainage.  There  was  no  leakage  and  the  child  made  an  unevent- 
ful recovery.  Nassau  does  not  regard  esophagotomy  as  a  serious 
operation,  but  believes  it  should  not  be  considered  until  efforts  at  ex- 
traction have  failed. 


Fig.  309. — Esophagot 
omy.   Final  incision. 

{Bryant.) 


CHAPTER  II. 

URGENT  THORACOTOMY.  REPAIR  OF  INJURY  TO  THE 
LUNGS.  REPAIR  OF  INJURY  TO  THE  PERICARDIUM; 
OF  INJURY  TO  THE  HEART.  PUNCTURE  OF 
THE  PERICARDIUM. 

As  has  been  indicated  elsewhere  (see  Injuries  of  the  Thorax),  urgent 
Intervention  for  injuries  of  the  thorax  is  a  form  of  operative  procedure 
at  this  present  time  with  but  a  limited  field.  Whatever  may  be  the 
apparent  gravity  of  the  case,  it  is  far  from  being  the  rule  to  operate, 
for  such  operations  require  trained  assistants,  a  special  equipment,  and 
a  superior  surgical  skill.  Of  necessity,  then,  in  general  practice,  the 
treatment  must,  generally  speaking,  be  conservative:  that  is  to  say, 
ck;i using  of  the  external  wound  with  enlargement  and  trimming  up 
if  necessary,  reunion  and  aseptic  occlusion,  firm  bandaging  of  the 
thorax,  and  an  absolute  quiet  in  bed.  These  measures  along  with 
stimulation  with  caffein  and  camphorated  oil  and  normal  salt  solution, 
represent  the  elements  of  treatment  which  are  within  the  scope  of  all. 

But  there  are  cases  so  manifestly  fatal  without  operation  that,  as 
Lejars  says,  one  cannot  evade  the  question,  "operate  or  let  die?" 

Grave  rupture  of  the  lung  indicated  by  an  immediate  flooding  of  the 
pleural  cavity,  followed  by  urgent  symptoms  of  asphyxia  and  syncope, 
is  the  signal  for  immediate  operation.  Again,  repeated  attacks  of 
secondary  hemorrhage  call  for  operation. 

URGENT   THORACOTOMY. 

The  technic  of  this  operation  can  be  exactly  defined  only  in  a  gen- 
eral way  and  will  need  to  be  modified  to  suit  the  individual  case. 

I. rjars  insists  that  the  opening  must  be  large,  that  anything  less  will 
le  a  disappointment  and  the  operation  might  as  well  not  be 
undertaken. 

423 


424  URGENT    THORACOTOMY. 

The  operation  may  proceed  in  one  of  two  ways:  (i)  by  a  permanent 
resection  of  the  ribs  necessary  to  be  removed,  or  (2)  by  temporary 
resection  with  the  formation  of  a  thoracic  flap. 

(1)  Make  a  U-shaped  incision  forming  a  flap  with  its  base  posterior, 
and  of  which  the  two  arms  run  parallel  with  the  ribs  and  are  wide 
enough  apart  to  include  at  least  three  ribs. 

The  incision  reaches  to  the  ribs.  Rapidly  dissect  up  this  musculo- 
cutaneous flap,  exposing  the  ribs  and  intercostal  muscles.  With  the 
flap  held  out  of  the  way,  begin  the  resection  of  the  ribs  by  incising  the 
periosteum  of  the  lowest  rib  along  its  middle  line,  the  full  length  of  the 
exposed  part.  Denude  the  rib  with  the  rugine.  Take  special  care  in 
the  denudation  along  the  lower  border  that  the  artery  and  nerve  re- 
moved with  the  periosteum  are  not  wounded.  Divide  the  inner  and 
the  outer  end  of  the  denuded  segment.  (See  Operation  for  Empyema.) 
Resect  the  other  ribs  exposed  in  the  same  manner. 

Raise  the  musculo-pleural  -flap.  Begin  by  dividing  the  upper  border; 
then  the  lower  border;  and  finally  the  anterior  border,  catching  each 
intercostal  artery  as  cut.     When  this  flap  is  lifted  the  lung  is  exposed. 

This  procedure  has  the  advantage  that  it  can  be  rapidly  carried  out; 
the  disadvantage,  that  it  permanently  sacrifices  a  part  of  the  bony 
wall  of  the  chest,  but  that  is  a  small  matter  in  the  face  of  such  emer- 
gencies. 

(2)  A  thoracic  flap  may  be  formed.  Make  the  same  "U  "-shaped 
incision  and  expose  the  ribs  as  in  the  preceding  operation.  Each 
costal  segment  is  then  denuded  of  periosteum  at  either  end  sufficiently 
for  the  passage  of  the  bone-cutting  forceps.  In  this  manner  each  rib 
is  divided  at  each  end. 

Next  carefully  divide  the  intercostal  muscle  parallel  with,  and  above, 
the  first  segment,  and  lift  the  anterior  end  of  this  rib,  and  begin  the 
separation  of  the  pleura. 

Work  along  the  front  at  first,  dividing  the  intercostal  muscles  and 
arteries  and  ligating  as  necessary.  The  liberation  of  the  flap  along 
the  lower  border  next  follows  and,  as  the  musculo-osseous  flap  is  more 
elevated,  the  separation  of  the  pleura  is  more  and  more  facilitated. 

Finally  the  flap  is  freed  and  turned  back  and  the  pleura  is  left  bared. 
The  pleura  is  next  divided  and  the  wounded  lung  is  now  freely  exposed. 


TREA  r\n  \  I    mi     INJURIES  TO   mi     ill  ART. 

Wipe  "ut  the  clots  and  seari  h  for  the  bleeding  surface,  [f  necessary 
a  hand  may  be  slipped  under  the  base  of  the  lung  pulling  it  forward 
for  inspection. 

Repair  the  lung.  The  idea)  method  is  by  suture,  employing  a  No. 
i  or  2  silk  thread  and  passing  it  through  the  parenchyma  with  a  round 
curved  needle.  If  this  is  not  possible  tamponade  is  the  next  resort. 
If  a  border  is  lacerated  and  projecting  it  may  be  ligated  en  masse  and 

reset  ted. 

Whether  or  qoI  drainage  is  employed  depends  upon  the  amount 
of  oozing  and  the  probabilities  of  infection.  If  infection  subsequently 
develops,  the  infected  area  is  to  be  opened  and  drained  as  any  other 

empyema. 

REPAIR  OF  INJURIES  TO  PERICARDIUM  AND  HEART. 

The  general  practitioner  does  not  see  many  injuries  to  the  heart. 
Gunshot  wounds  are.  of  course,  usually  immediately  fatal;  so  that  the 

form  of  cardiac  injury  most  likely  to  present  itself  for  treatment  is  a 
stab  wound.  Occasionally  the  heart  is  lacerated  by  a  broken  rib. 
The  sudden  death  from  cardiac  wounds  may  occur  in  several  ways. 
It  may  occur  from  syncope  arising  from  the  pressure  of  the  Mood 
within  the  pericardium;  or  the  heart  may  be  unable  to  contract  be- 
cause of  its  divided  libers  and  cerebral  anemia  follows;  or  shock  or 
pulmonary  edema  may  be  the  immediate  cause  of  death. 

Even  if  death  does  not  immediately  occur,  hemorrhage  and  infection 
may  later  provoke  a  fatal  issue  (See  Injuries  to  the  Thorax,  page  99). 

The  treatment  of  traumatisms  of  the  heart  and  pericardium  has 
three  ends  in  view;  to  combat  shock,  to  control  hemorrhage,  and  to 
prevent  infection. 

Keep  the  patient  absolutely  quiet,  lower  the  head,  apply  artificial 
heat,  give  morphine  in  small  doses  (1/8  gr.)  hypodermically ;  and, 
if  there  is  an  open  wound  in  the  chest,  disinfect  and  dress  asepti- 
cally,  but  do  not  operate  merely  to  disinfect. 

If  the  In-art  is  injured  sufficiently  to  bleed,  operate.  The  sole  in- 
dication, then,  for  operative  treatment  is  hemorrhage. 

The  patient    will   probably  die  even   if  operated   upon,  but  he  will 


426 


URGENT   THORACOTOMY. 


most  certainly  die  without  the  operation;  so  that  it  is  our  duty  to  give 
him  the  additional  chance  which  intervention  offers. 

If  the  wound  seems  likely  to  have  reached  the  heart;  if  there  is 
bleeding;  if  there  is  pain  and  precordial  oppression;  if  there  are  fre- 
quent attacks  of  syncope;  if  there  are  signs  of  increase  of  fluids  about 


Fig.  310. — Forming  the  costal  flap.  The  three  ribs  in  the  flap  are  divided  near 
the  sternum,  and  the  upper  and  lower  ribs  divided  at  the  outer  limit  of  the  flap. 
The  middle  rib  to  be  fractured  by  raising  the  flap. 

the  heart;  then  one  is  justified  in  believing  that  the  heart  has  been 
wounded  sufficiently  to  produce  hemorrhage  and  must  prepare  im- 
mediately for  the  operation.  There  must  be  no  delay.  It  will  depend 
upon  the  degree  of  urgency  whether  the  time  shall  be  taken  for  formal 
preparation  of  the  field.     However  indispensable   asepsis  may  be. 


OP]   R  \Tli)\     | OK     Rl  PAIB    OB    TIM      III  ART.  \2~, 

yet  hemostasis  in  such  cases  is  the  more  urgent  indication.  Even  in 
the  mosl  desperate  i  asesone  must  at  least  s<  rub  his  hands  and  wash  (lie 
Beld,  for  there  is  little  use  to  check  tin-  hemorrhage  it"  the  patient  is  to 

die  later  fnmi  sepsis.  While  the  anesthesia  IS  under  way,  the  skin 
may  he  washed  with  soap  and  water  followed  by  alcohol  and  bichloride 

solution;  or  Tr.  iodine  mav  be  used  on  the  <\r\  skin. 


FlO.  311. — Costal  Sap  reflected.     Pleura  retracted.      Edges  of  pericardial  wound 
held  in  forceps  and  heart  wound  exposed. 

(lateral  Anesthesia. — Ether  should  be  employed  if  the  patient's  con- 
dition will  permit. 

The  opt  ration  proposes  to  make  a  thoracic  flap,  to  open  the  peri- 
cardium and  expose  the  heart,  and  to  repair  the  injury.  There  is 
no  operation    that   requires   more   decision,   courage,  and  self-control. 

Incision-   Begin   in  the  third  intercostal  space  just  in  front  of  the 


428 


URGENT   THORACOTOMY. 


anterior  axillary  border  and  cut  inward  to  the  border  of  the  sternum, 
abruptly  curving  there  and  following  the  sternal  border  downward 
to  the  sixth  space;  again  abruptly  curving  and  following  that  space 
outward  (Fig.  310).  These  incisions  expose  the  ribs  and  intercostal 
muscles. 


Fig.  312. — Heart  supported  in  palm  of  hand  preparatory  to  suturing.      (After  Lejars.) 


Formation  of  the  Flap. — Divide  the  fourth,  fifth,  and  sixth  cartilages 
near  the  sternum  and  also  the  intercostal  muscles,  along  the  line  of  the 
original  incision. 

At  the  lower  outer  angle  of  the  incision,  expose  the  sixth  rib  by 


SV  I TKI     OF    WOUND    OF    llll     HI   U'T. 


429 


pulling  the  tissues  upward.     Incise  the  periosteum  over  its  external 

surface  and  with  the  rugine  free  the  rib  of  periosteum  and  divide  it 
At  the  upper  outer  angle  expose  the  fourth  ril>,  free  it  of  periosteum, 
and  with  the  costotome  <»r  a  bone-cutting  forceps,  divide  it  in  the 
same  way.  The  flap  is  now  attached  only  by  the  fifth  rib  which  is  t<> 
be  fractured.  Raise  the  sternal  end  of  the  flap  with  the  left  hand  and 
press  on  the  fifth  rib  with  the  right  hand  and  with  a  little  force  the  rib 
is  broken  in  the  line  of  section  of  the  other  two  ribs. 

The  flap  is  now  gradually  raised  as  its  adhesions  to  the  subjacent 
structures  are  freed,  and  the  pleura  is  exposed. 


r?c 


Fig.  313. — Suture  of  wound  of  heart.  Fig.  314. — Suture  of  heart  completed. 


If  there  is  a  wound  in  the  pleura,  it  may  be  enlarged  and  the  pericar- 
dium may  lie  reached  through  it;  otherwise  proceed  to  the  liberation 
and  retraction  of  the  pleura.  With  a  grooved  director,  liberate  the 
fibrous  attachments  of  the  triangularis  sterni  to  the  posterior  surface 
of  the  sternum,  which  at  the  same  time  liberates  the  pleura.  With 
the  fingers,  draw  outward  the  free  border  of  the  pleura  with  its  covering 
the  triangularis  sterni  (Fig.  311).  In  this  manner  is  the  pericardium 
exposed.     The  assistant  holds  the  pleura  with  a  retractor. 

Incision  of  the  Pericardium. — Enlarge  the  wound  in  the  pericardium 
and  in  that  manner  expose  the  heart.  Retract  the  edges  of  the  peri- 
cardial wounds  with  forceps.      Locate  the  wound  in  the  heart.     Slip 


430  URGENT   THORACOTOMY. 

the  left  hand  under  the  apex  and  pass  the  first  suture,  and  the  heart 
may  be  thereafter  steadied  by  traction  on  the  threads  of  the  first  suture 
(Fig.  312). 

Suture  the  wound  in  the  heart.  Use  either  interrupted  or  continuous 
suture  of  catgut.  There  is  no  particular  advantage  in  passing  the 
suture  in  diastole.  Pass  them  deeply,  but  not  to  the  endocardium 
(Figs.  313,  314). 

Now  wipe  out  the  pericardium  with  sterile  compresses  and  repair 
the  pericardium  by  continuous  catgut  suture.  Next,  wipe  out  the 
adjacent  portion  of  the  pleural  cavity,  repair  any  part  of  the  lung 
that  may  be  injured  and  repair  the  pleura  without  drainage.  Finally, 
replace  the  thoracic  flaps,  and  suture.  It  is  generally  wise  to  excise 
the  tissues  along  the  mark  of  the  wound. 

No  drainage  is  to  be  employed  except  under  these  circumstances: 
if  the  case  was  operated  on  late  and  there  is  great  probability  of 
infection,  it  is  better  to  leave  drainage  in  the  pleural  wound,  pro- 
jecting from  the  thorax  at  the  lower  angle  of  the  skin  wound;  if  there 
is  much  oozing,  it  is  better  to  leave  a  wick  of  gauze  in  the  pleural  wound. 

A  case  of  successful  suture  by  Gibbon,  of  Jefferson  Medical  College, 
illustrates  the  subject  (Jour.  American  Medical  Assn.,  Feb.  io7  1906). 
Patient,  aged  38,  healthy  colored  man.  Stab  wound  of  chest,  a  few 
moments  after  which  he  fell  unconscious.  An  hour  later  at  the  hos- 
pital his  condition  was  very  grave:  unconscious,  cyanosed,  pupils 
dilated,  skin  cold  and  moist,  respiration  rapid  and  shallow.  No  pulse 
in  the  peripheral  vessels  and  the  heart  sounds  were  distant,  rapid,  and 
irregular. 

Vigorous  stimulation  was  employed  with  morphia  and  atropia, 
and  his  condition  slightly  improved.  Operation  about  one  and  one- 
half  hours  after  the  injury.     Only  a  small  quantity  of  ether  required. 

The  fourth  costal  cartilage  was  found  and  divided  and  the  entire 
cartilage  and  a  part  of  the  rib  was  removed.  The  pericardium 
was  explored  and  a  wound  located  which  would  only  admit  tip  of 
index  finger.  This  pericardial  wound  was  enlarged  and  the  sac 
'emptied  of  clots  and  liquid  blood.  It  began  rapidly  to  fill  again. 
Two  fingers  passed  under  the  heart  lifted  it  up  into  the  pericardial 
opening  and  with  rapid  sponging,  the  wound  was  located.     It  was 


R]  PAIS    01    WOUND   "l     I  III     III  MM'.  IS  i 

situated  in  the  right  ventricle  near  the  auriculo  ventrii  ular  groove. 
It  bleed  freely,  controlled  by  pressure;  wasaboul  three-fourths  inch 
in  length.  The  wound  in  the  endocardium  was  about  one  half  as 
Long. 

A  traction  suture  of  cbromicized  catgut  was  passed  through  both 
edges  and  by  that  means  the  heart  was  held  in  position,  while  four 
other  sutures  were  passed  and  no  effort  was  made  to  avoid  the  en- 
docardium. A  small  gauze  drainage  was  applied  to  the  line  of 
sutures  and  brought  out  through  the  pericardial  wound  which  was 
not  sutured. 

During  the  subsequent  twelve  hours  there  was  enough  oozing 
to  require  a  change  of  dressing.  His  general  condition  was  fairly 
good.  The  second  day  his  condition  was  alarming;  respirations  62. 
The  gauze  was  found  to  be  interfering  with  drainage  and  removed. 
The  respirations  fell  to  38  in  a  short  time. 

Large  quantities  of  salt  solution  were  given  by  rectum.  Liquid 
food  on  second  day.  The  dressings  were  changed  every  other  day. 
Six  days  after  the  operation  the  skin  wound  was  sutured  almost  com- 
pletely, the  wound  in  the  pericardium  being  practically  healed. 
In  six  weeks  he  returned  to  work  completely  recovered,  with  heart's 
action  regular  and  normal. 

Gibbon  does  not  advise  an  osteo-plastic  flap  unless  a  pleural  wound 
is  demonstrated,  believing  it  best  to  excise  as  much  of  the  sternum 
or  cartilage  or  rib  as  may  be  necessary  to  give  free  access.  He  em- 
phasizes the  value  of  the  traction  suture,  and  advises  the  repair  of 
the  pericardial  wound  without  drainage,  but  would  always  drain  the 
external  wound. 

Travers  (Lancet,  Sept.,  1906)  operated  upon  a  case  in  which  the 
patient  was  Impaled  upon  a  spike  fence.  The  right  ventricle  was 
torn,  the  spike  penetrating  the  sternum  to  reach  it.  The  wound 
in  the  heart  was  closed  by  twenty  sutures.  The  patient  did  very  well 
up  to  the  eleventh  day,  when  he  died  from  heart  failure,  due  to  the 
pressure  of  a  slowly  forming  clot. 

Travers  notes  that  the  suturing  seemed  to  stimulate  the  flagging 
heart. 

Stewart,  among  the  first  in  the  United  States  to  suture  the  heart 


432  URGENT   THORACOTOMY. 

successfully,  turned  the  musculo-cutaneous  flap  to  the  left  and  the 
thoracic  flap  to  the  right,  fracturing  the  cartilages  near  the  base  of  the 
sternum. 

The  pericardial  wound  was  enlarged  in  the  axis  of  the  heart.  The 
heart  wound,  produced  by  a  stab  with  a  long,  rusty  pen-knife,  involved 
the  thickness  of  the  left  anterior  ventricular  wall,  ran  parallel  with  the 
axis  of  the  heart,  and  was  about  three-fourths  of  an  inch  in  length,  was 
larger  than  either  the  skin,  pleural,  or  pericardial  wound.  The  heart 
bled  freely  and  continuously,  and  resembled  a  mere  quivering  mass 
of  muscle. 

The  wound  was  closed  with  a  continuous  silk  suture,  the  pericardial 
cavity  cleansed  and  the  sac  sutured  with  silk.  A  gauze  drain  was 
left  at  the  lower  angle.  The  pleural  cavity  was  cleansed  and  irri- 
gated with  salt  solution.  The  thoracic  flaps  were  sutured  with  silk- 
worm-gut and  a  gauze  drain  left  also  in  the  pleural  cavity. 

During  the  operation,  which  lasted  about  forty-five  minutes,  twenty- 
four  ounces  of  salt  solution  and  adrenalin  were  injected,  and  strychnin 
and  atrophia  given  hypodermically. 

Some  infection  followed,  and  by  the  eighth  day,  the  temperature 
was  1030,  pulse  150,  and  respiration  50.  From  that  time,  the  symptoms 
of  sepsis  gradually  declined  until  at  the  end  of  three  weeks,  these  con- 
ditions were  practically  normal;  at  the  end  of  the  fifth  week,  the  patient 
was  out  of  bed. 

Stewart,  discussing  the  operation  (American  Journal  Med.  Sciences, 
Sept.,  1904),  notes  that  the  size  of  the  heart  wound  cannot  be  predicated 
from  the  external  wound;  and  concludes  that  the  only  safe  procedure 
in  doubtful  cases  is  to  enlarge  the  wound  and  ascertain  if  it  penetrates 
the  chest  wall;  and  if  there  be  symptoms  of  hemorrhage — of  heart 
tamponade — operate. 

In  all  of  these  cases  already  mentioned,  it  was  the  ventricle  which 
required  repair.  Peck,  of  New  York,  describes  a  case  in  which  it  was 
necessary  to  suture  the  auricle  (Annals  of  Surgery,  July,  1909). 

The  patient,  a  colored  girl  twenty-four  years  of  age,  was  brought 
to  the  hospital  suffering  from  a  stab  wound  over  the  third  costal  carti- 
lage at  the  left  border  of  the  sternum.  Her  condition  was  grave:  no 
radial  pulse;  the  heart  sounds  could  not  be  heard;  respiration  faint  and 


PUNCTVKK    01    mi     PERICARDIUM.  433 

■hallow,  and  the  extremities  cold;  operation  begun  about  forty-six 
minutes  after  the  receipt  of  the  injury. 

A  quadrangular  Sap  of  the  soft  parts  with  base  external  was  dissei  ted 
lack.  The  third,  fourth,  fifth  and  sixth  cartilages  were  divided  at 
the  sternal  junction,  and  the  third,  fourth,  and  fifth  ribs  near  the 
coSto  chondral  junction,  and  the  flap  turned  out  and  the  internal 
mammary  ligated  above  and  below.  The  pericardial  wound  was  near 
the  border  of  the  sternum,  a  part  of  which  was  resected  with  rongeur 
foncps  to  give  a  better  view.  The  tense  pericardium  was  incised  and 
the  clots  emptied  out,  whereupon  the  radial  pulse  could  be  felt. 

The  bleeding  seemed  to  come  from  the  upper  part  of  the  cavity  but 
She  rapidly  beating  heart,  churning  the  free  blood,  made  it  impossible 
to  locate  the  wound  until  a  transverse  cut  in  the  sac  gave  a  better 
exposure. 

Lifting  the  heart  forward  and  slightly  rotating  it  to  the  left,  a  wound 
of  the  right  auricle  was  brought  into  view.  With  each  systole  a 
tream  of  dark  blood  spouted  two  or  three  inches.  Four  sutures  of 
chromicized  catgut  passed  on  a  curved  intestinal  needle  controlled 
the  bleeding.  The  pericardium  was  cleansed,  closed  without  drainage 
with  continuous  chromic  catgut  suture.  The  cartilaginous  flap  was 
carefully  sutured  with  No.  3  chromicized  gut  and  the  soft  parts  with 
ratgut  and  silkworm-gut.  No  drainage  was  used.  The  operation 
asted  sixty-five  minutes,  during  which  time  1900  C.  of  normal  salt 
iolution  was  given  intravenously.  For  the  first  six  or  seven  days  there 
were  signs  of  mild  pleurisy  and  the  temperature  ranged  from  100  to 
102.8,  pulse  116  to  136;  but,  at  the  end  of  two  weeks,  these  were 
practically  normal,  and  at  the  end  of  another  week,  she  was  discharged, 
quite  well. 

It  will  be  observed  that  the  incision  and  flap  formation  differed  with 
lach  operation,  no  one  method  can  be  insisted  upon  to  the  exclusion 
Df  all  others. 

PUNCTURE  OF  THE  PERICARDIUM. 

Puncture  of  the  pericardium — paracentesis  pericardii — is  indicated 
n  those  cases  of  hemo-pericardium  and  serous  effusion  in  which 
:he  accumulating  fluids  dangerously  interfere  with  the  functions  of 
28 


434 


URGENT    THORACOTOMY. 


the  heart.  The  physical  signs  and  the  symptoms  point  to  the  nature 
of  the  difficulty.  It  is  not  more  frequently  done  because  of  the  in- 
stinctive fear  that  one  may  wound  the  heart;  indeed  there  are  three 
structures  which  may  be  wounded  with  serious  consequences;  the  heart, 
the  pleura,  and  the  internal  mammary  artery. 

The  puncture  may  be  made  near  the  sternum  to  the  inside  of  the 
internal  mammary;  it  may  be  made  to  the  outside  of  the  internal 


Fig.  315. — Puncture  of  the  pericardium  and  pericardiotomy;  vertical  lines,  represent  the 
anterior  border  of  pleura  and  lung.  The  •  represents  sites  of  puncture.  "^~,  line  of 
incision  for,  and  portion  of  rib  resected  in,  pericardiotomy. 


mammary,  between  it  and  the  line  of  the  lung.  The  latter  is  per- 
haps the  better  (Fig.  315). 

The  point  of  entrance  of  the  needle  is  in  the  fifth  left  intercostal  space, 
6  cm.  from  the  sternal  border.  Use  a  small  trocar  or  an  aspirator. 
Cleanse  the  field  thoroughly.  Put  the  patient  in  a  half  reclining  posi- 
tion on  his  bed  and  mark  with  the  left  index  finger  the  site  of  the 
puncture. 

Direct  the  needle  obliquely  downward  and  inward  and  do  not 


PURULENT    PERICARDITIS.  435 

penetrate  deeper  than  2.5  cm.,  holding  the  needle  so  as  to  regulate 
its  progress. 
As  the  pericardium  empties  Itself,  gradually  elevate  the  trocar  so 

as  not  to  wound  the  heart. 

PURULENT  PERICARDITIS.     PERICARDIOTOMY. 

If  the  exploratory  puncture  demonstrates  the  presence  of  pus,  the 
only  rational  treatment  is  drainage,  unless  the  patient  is  moribund.  To 
incise  and  empty  the  pericardium  is  the  only  procedure  that  offers  any 
hope  of  permanent  relief. 

Operation. — Begin  by  locating  the  attachment  of  the  fifth  costal 
cartilage  and  the  middle  of  the  sternum. 

Incision. — From  the  middle  of  the  sternum  horizontally  outward 
over  the  center  of  the  fifth  cartilage  on  the  left  side,  to  the  costo- 
chondral  junction.  Deepen  the  incision  so  as  to  divide  all  the  soft 
parts  down  to  the  cartilage.  Strip  back  the  covering  of  the  cartilage 
with  the  rugine  (Fig.  315). 

Resect  the  cartilage  at  its  sternal  junction  and,  gently  lifting  up,  grad- 
ually detach  its  coverings  behind  out  to  the  junction  of  the  rib.  Here 
it  may  be  fractured  or  permanently  resected.  Dividing  their  sternal 
attachments,  retract  the  intercostal  muscles  with  the  arteries  in  the 
space  opened  up  and  thus  expose  the  pleura. 

Detach  the  pleura  by  loosening  the  sternal  attachments  of  the  tri- 
angularis which  allows  the  pleura  to  be  drawn  outward.  This 
should  be  done  with  the  finger  passed  under  the  sternum  and  hooked 
around  the  border  of  the  pleural  sac.  The  pericardial  sac  is  now 
exposed. 

Incise  the  pericardium,  first  catching  up  a  fold  between  two  forceps, 
and-  dividing  it  with  scissors.  If  possible,  the  edges  of  the  pericardial 
wound  should  be  stitched  to  the  margin  of  the  skin  wound. 

Insert  gauze  drainage:  A  rubber  tube  is  too  likely  to  irritate  the  heart. 
This  operation  is  often  followed  by  recovery  without  any  impairment 
of  the  heart's  action. 


CHAPTER  III. 
EMPYEMA— PURULENT  PLEURISY. 

Various  bacteria  may  attack  the  pleura,  most  frequently  they  are 
the  pneumococcus,  the  streptococcus,  the  staphylococcus,  the  bacillus 
tuberculosis,  or  the  bacillus  communi  coli. 

The  pneumococcus  is  usually  present  in  the  empyema  of  childhood. 
Be  on  your  guard  for  empyema  especially  in  whooping-cough. 

The  clinical  history  and  the  prognosis  vary  in  different  forms  of 
the  disease  and  are  directly  dependent  upon  the  form  of  the  infection. 

But,  whatever  the  pyogenic  agent,  when  pus  has  once  formed  in  the 
pleural  cavity,  it  seeks  for  an  outlet  in  various  directions.  It  may 
rupture  into  a  bronchus  and  escape  by  the  mouth,  and,  under  these 
circumstances,  pneumothorax  may  ensue;  it  may  perforate  the  chest 
wall,  manifesting  itself  as  an  external  abscess  of  various  forms;  it  may 
open  into  the  pericardium,  esophagus,  or  stomach. 

In  every  case,  the  longer  relief  is  delayed,  the  greater  the  probability 
that  the  lung  will  be  permanently  collapsed  or  bound  down  by  ad- 
hesions. Finally,  in  some  degree,  there  are  always  the  evil  results  of 
sepsis.  There  is  every  reason,  then,  when  pus  is  known  to  exist  in  the 
pleural  cavity,  to  drain  without  delay. 

The  diagnosis  rests  upon  the  history  of  the  case  (remembering  that 
this  history  will  vary  with  the  form  of  infection),  upon  the  pain,  the 
constitutional  symptoms  which  are  those  of  sepsis  generally,  and  upon 
the  physical  signs.  These  are:  distention  of  the  thorax  accompanied 
perhaps  by  edema  of  the  chest  wall;  flatness  on  percussion  and  evident 
displacement  of  neighboring  organs;  absence  of  the  vesicular  murmur, 
and  the  presence  of  bronchial  breathing. 

Taylor,  of  Springfield  (Illinois  Med.  Jour.,  1907),  attributes  the 
most  frequent  source  of  error  in  diagnosis  to  a  misconception  of  the 
position  assumed  by  the  exudate. 

Physicians  are  observed  trying  to  establish  a  horizontal  line  for 

436 


I   MM.OKATORY    1TNC II   Ki;    nr    Till.    I'l.KlKA. 


437 


tin'  exudate  with  the  patient  in  the  sitting  posture,  under  the  impression 
that  the  fluid  will  follow  the  influence  of  gravity.  But  this  is  the 
exception  rather  than  the  rule.  The  dullness  is  usually  higher  pos- 
teriorly. The  "S  "-shaped  line  of  Ellis,  if  present  at  all,  is  so  variable 
from  day  to  day  as  to  be  of  minor  importance.  Taylor  remarks  further 
that  the  character  of  the  fluid  is  often  a  matter  of  doubt.  Chills 
and  variable  temperature  point  to  pus,  although  he  has  seen  patients 


Fig.  316. — Puncture  of  the  pleura.     (Lciars.) 


recovering  from  pneumonia  who  had  none  of  these  symptoms  and 
yet  carried  around  three  pints  of  pus  in  the  pleural  cavity. 

Most  of  the  signs  and  symptoms  may  occur  as  well  with  pleurisy 
with  effusion,  and  it  is  only  by  exploratory  puncture  that  the  matter 
may  be  definitely  determined. 

Exploratory  puncture,  then,  is  the  court  of  final  resort  and  must 
always  be  employed  before  deciding  upon  the  form  of  treatment. 


438  EMPYEMA PURULENT  PLEURISY. 

PUNCTURE  OF  THE  PLEURA. 
Let  the  patient  lie  on  the  sound  side  with  his  shoulders  elevated 
and  the  arm  of  the  affected  side  extended  above  the  head,  the  effect  of 
which  is  to  widen  the  intercostal  spaces.  Locate,  for  example,  a  point 
in  the  axillary  line  and  the  sixth  intercostal  space.  Freeze  the  skin 
with  ethyl  chloride  or  inject  a  little  cocaine  at  the  site  of  puncture. 
Press  a  finger  into  the  intercostal  space  and  locate  the  lower  border  of 
the  rib.  With  the  finger  as  guide  enter  the  needle  so  as  to  avoid 
the  rib  and  thrust  it  inward  and  slightly  upward.  One  can  readily 
determine  whether  it  has  reached  the  pleural  cavity 
by  the  degree  of  resistance.  Enough  fluid,  whether 
pus  or  serum,  will  escape  through  the  aspirating 
needle  to  make  its  presence  certain;  but  in  order  to 
draw  off  any  quantity  an  aspirator,  of  which 
Potain's  (Fig.  316)  is  the  best  type,  must  be  at- 
tached. A  serous  pleuritic  effusion  is  relieved  by 
aspiration.  Sometimes  removal  of  even  a  small 
quantity  will  start  absorption  in  a  case  of  long 
standing.  If  the  fluid-  is  pus,  the  subsequent 
fig.  317:— Empyema:     course  is  quite  different. 

^avftytothLhestwai!         As  has  been  said,  every  purulent  pleurisy  must 
and  lung.    (Veau.)         ^Q  0peneci  as  soon  as  possible,   must  be  opened 

freely  and  at  its  lower  point. 

In  the  case  of  a  child,  it  suffices  usually  to  incise  the  intercostal 
space  in  order  to  perfect  a  cure.  In  the  case  of  the  adult,  it  is  nec- 
essary to  resect  a  rib  for  adequate  drainage,  and  even  then  the  patient 
may  shortly  die  or  retain  a  chronic  sinus.  These  possibilities  should 
always  be  explained  before  the  operation,  necessary  but  disagreeable, 
is  undertaken.  As  a  rule  it  is  advisable,  we  will  say,  to  resect  a  rib, 
although  in  the  recent  case,  uncomplicated,  obviously  benign,  a  good 
result  may  be  obtained  by  simple  incision.  Carsterls,  of  Detroit,  has 
recently  said  he  thinks  we  resect  far  too  many  ribs  in  these  conditions. 

Site  of  the  Incision. — The  cavity  must  be  opened  where  it  will  drain 
best  in  the  recumbent  position.  The  lowest  level  of  the  abscess  can  be 
determined  only  by  exploratory  puncture;  any  other  method  is  useless. 
Having  already  confirmed  the  diagnosis  by  puncture,  now  at  the  begin- 


OP]  B  \  I  [I  'v-     I  OB    I  M  I  *  N  I  MA.  430 

■ng  of  the  operation,  make  another  exploratory  puncture  in  the  spa<  e 
next  lower.     H"  pus  is  found  there,  puncture  again  in  the  space  below, 

and  so  on  until  no  pus  is  found.    The  last  puncture  producing  pus 
will  In'  tin'  site  of  the  incision. 

Anatomy  (Fig.  517). — The  aim  will  hi'  to  incise  parallel  with  the  rib. 
In  going  through  the  structures  of  the  intercostal  space,  remember 
that  the  vessels  and  nerve  lie  in  or  near  the  groove  in  the  lower  border 
of  the  rib.  Incising  any  space,  therefore,  keep  close  to  the  lower 
line  of  the  space,  keep  near  the  upper  border  of  the  rib  forming  the 
lower  boundary  of  the  space.  If  a  rib  is  to  be  resected,  it  should  be 
denuded  of  its  periosteum,  which  is  loosely  attached  and  on  that 
account  easily  stripped  off. 

EMPYEMA  IN  THE  CASE  OF  A  CHILD. 

In  the  case  of  a  child,  simple  incision  of  the  pleura  will  suffice. 
Under  general  anesthesia,  if  the  condition  of  the  patient  will  permit, 
make  an  incision  three  or  four  inches  long,  parallel  with  the  ribs. 
The  incision  traverses  the  skin,  and  beneath  it  a  cellular  layer,  often 
edematous.     Next  divide  the  muscles,  letting  the  rib  serve  as  a  resist- 


I"ir,.  318. — Incision  of  the  pleura  without  resection  of  a  rib.      (Schwartz.) 

ing  plane.  In  front  they  are  thin  (pectoralis  major);  behind,  thicker 
(latissmus  dorsi  and  serratus  magnus).  Divide  them  at  a  single 
stroke  and  without  concern.     A  small  artery  may  need  to  be  clamped. 

Having  exposed  the  rib  (Fig.  318),  retract  the  upper  lip  of  the  wound 
and  locate  the  upper  border  of  the  rib;  below,  it  bounds  the  space  about 
to  be  penetrated.  Following  this  border,  incise,  layer  by  layer,  the 
intercostal  muscles.  There  is  never  any  serious  hemorrhage.  As  you 
approach  the  pleura,  be  prepared  for  a  sudden  spurt  of  pus,  and,  when 


440  EMPYEMA — PURULENT  PLEURISY. 

the  pus  flows,  it  is  evident  the  pleura  is  opened.  Enlarge  the  opening, 
using  the  left  index  finger  as  a  guide.  Incline  the  patient  so  that  the 
cavity  may  be  entirely  emptied.     Fix  the  drainage-tube  (see  further). 


Fig.  319. — Incision  of  the  costal  periosteum.     (V euu.) 

EMPYEMA  IN  THE  CASE  OF  AN  ADULT. 

In  the  case  of  empyema  in  an  adult,  it  is  usually  necessary  to  resect 
a  rib.  One  needs  a  bone-cutting  forceps  or  a  costotome  and  a  curved 
periosteal  elevator  or  rugine  in  addition  to  the  ordinary  instruments. 

Local  Anesthesia. — It  is  a  grave  error  to  give  chloroform,  for  it  is  more 


Fig.  320. — Uncovering  the  posterior  surface  of  the  rib  with  rugine.     {Schwartz.) 

than  likely  to  hasten  the  patient's  death.  It  is  rare  in  such  a  case 
that  any  form  of  general  anesthesia  is  safe,  still  it  may  be  necessary 
with  the  excessively  timorous. 

Having  determined  the  site  of  incision  by  exploratory  puncture, 
incise  the  skin  and  muscles  as  in  the  case  of  a  child.     The  length  of 


OPl  B  \i  [ON    l  OB    I  \ll'\  I  U  \.  441 

the  incision  will  equal  four  fingers1  breadth.     When  the  rib  is  ex- 
posed, divide  its  periosteum  in  the  middle  line  (Fig.  319). 

The  denudation  of  the  rib  is  an  important  step.      With  the  nigine  OT 
curved  periosteal  elevator,  uncover  the  upper  half  of  the  external  sur- 


Fi':.  321. — Section  of  the  rib.     (Schwartz.) 

face  of  the  rib  first  and  then  the  lower  half,  keeping  very  close  to  the 
rib  as  you  reach  the  lower  border,  so  as  not  to  wound  the  intercostal 
vessels  or  nerve,  which  are  closely  attached  to  the  periosteum  and  are 
removed  with  it.  Finally,  uncover  the  deep  surface  of  the  rib.  Care- 
fully slip  the  elevator  upward  between  the  bone  and  its  periosteum, 


Fig.  322. — Section  of  the  rib.     (Schwartz.) 

which  is  loosely  attached  (Fig.  320).  Carry  the  elevator  to  one  end  of 
the  section  and  then  to  the  other  and  the  part  of  the  rib  to  be  removed 
is  thus  entirely  freed  from  its  periosteal  attachment. 

Divide  the  rib.     Introduce  one  blade  of  a  bone  forceps  or  costotome 
under  one  end  of  the  section  to  be  removed  and  divide  it  (Fig.  321). 


442 


EMPYEMA PURULENT  PLEURISY. 


Then  divide  the  other  end  (Fig.  322).  The  bone  removed  should  be 
two  and  one-half  to  three  inches  long.  The  stumps  should  not  project 
beyond  the  limit  of  the  flesh  wound,  else  necrosis  is  favored. 

Incise  the  pleura.     With  the  rib  removed,  the  periosteum  remains 
attached  to  the  pleura  and  this  periosteal  layer  is  incised  along  its 


/* 


Fig.  323. — Rib  removed,  pleura  incised.     (Veau.) 


middle  (Fig.  323),  and  the  pleura  is  divided  at  the  same  time.     Be 
on  your  guard,  when  making  the  incision,  for  a  spurt  of  pus. 

Empty  and  drain  the  cavity.  Incline  the  patient  to  one  side  and 
instruct  him  to  cough.  The  pus  pours  out,  often  offensively  fetid. 
Take  plenty  of  time.  Finally,  wipe  out  the  cavity  with  sterile  gauze. 
Irrigation  is  usually  inadvisable;  but,  if  used,  employ  only  warm,  sterile 


Fig.  324. — Drainage  of  the  pleural  cavity.      (Veau.) 

water,  salt  solution,  or  a  weak  solution  of  peroxide.  The  stronger 
antiseptics  are  dangerous.  Do  not  suture  the  wound  except  to  cover 
over  the  projecting  end  of  the  divided  rib.  The  difficulty  is  to  keep  the 
wound  open. 

Drainage  must  never  be  neglected.     Employ  two  large  and  long 


l>K  VINAG1     l  I  >K    l  \ll'\  l  MA.  1  \  J 

libes  placed  in  different  directions  and  anchor  with  safety  pins    I 
■24)  <>r  by  a  suture,  else  they  may  be  lost  in  the  abscess  cavity. 

Dressing. — This  is  important.  Pack  moist  sterile  or  boracic 
lauze  all  around  the  tubes,  between  the  lips  of  the  wound.  Apply 
an  ample  dressing  of  absorbent  COtton,  which  covers  half  the  thorax, 
and  hold  all  in  place  with  a  large  flannel  bandage  maintained  by 
suspenders.  Let  the  patient  occupy  the  half-sitting  position,  in- 
clined toward  the  affected  side  and  supported  by  pillows  at  the  bai  k. 

Subsequent  Care.-  After  a  few  hours,  change  the  dressing,  which  is 
usually  saturated,  hut  do  not  disturb  the  drains.  Change  the  dressing 
twice  daily  until  the  discharge  diminishes  and  about  the  third  day 
withdraw,  cleanse,  and  replace  the  tubes  in  the  same  place  and  to  the 
tame  depth;  else  look,  for  trouble,  if  you  fail  to  accomplish  this. 

Do  not  irrigate  while  making  these  dressings,  unless  the  discharge 
has  persisted  undiminished  for  a  week  and  continues  fetid,  when  it  is 
best  to  use  a  sterile  wash  of  salt  solution  or  dilute  peroxide,  which 
is  to  be  injected  under  very  slight  pressure. 

The  end  results  vary  with  the  nature  of  the  infection. 

(1)  The  metapneumonic  pleurisy  of  children  is  usually  cured. 
About  the  fifteenth  day,  smaller  tubes  may  be  used  and  are  gradually 
to  be  shortened  as  granulation  proceeds.  In  the  fortunate  case,  the 
opening  will  close  in  something  like  two  months. 

(2)  In  tubercular  pleurisy  with  secondary  infection,  cure  scarcely 
ever  takes  place.  The  patient  will  probably  die  in  a  few  months  of 
amyloid  degeneration.  Even  if  the  patient  does  not  die  soon,  the 
suppuration  shows  little  tendency  to  yield.  In  these  cases  with  per- 
sistent sinus,  the  bismuth  paste  injection  often  hastens  a  cure. 

(3)  Streptococcic  or  staphylococcic  pleurisy:  The  patient  may  go  on 
to  death  or  else  recovers  with  persistent  sinus.  Keep  the  orifice  open, 
for  if  the  pus  is  allowed  to  accumulate,  it  will  be  necessary  to  operate 
kgain.  Keep  watch  on  the  functions  of  the  kidney  and  liver.  Re- 
member the  frequency  of  metastatic  abscess,  as  of  the  brain,  for 
example. 

After  two  to  four  months,  the  case  may  be  referred  to  a  specialist 
for  a  plastic  operation. 


CHAPTER  IV. 
URGENT  CRANIECTOMY:  TREPHINING. 
FRACTURE  OF  VAULT  OF  THE  SKULL. 

There  are  two  conditions  which  may  accompany  fracture  of  the 
skull,  singly  or  together,  either  of  which  demands  immediate  relief. 
(See  Fracture  of  the  Skull.) 

(A)  The  depressed  fragments  have  contused  and  lacerated  the  brain; 
consciousness  was  immediately  lost  and  was  not  regained.  Under  these 
circumstances,  the  fragments  must  be  elevated  without  delay. 

(B)  Hemorrhage  has  occurred  within  the  cranial  cavity  and  the 
clot  compresses  the  brain.  In  this  case,  there  is  a  "free  interval." 
The  patient  regains  consciousness  and,  perhaps,  for  a  time — two  to 
twenty-four  hours — appears  not  to  be  seriously  injured,  but  little  by 
little  the  signs  of  "compression"  develop,  namely,  restlessness,  dull- 
ness, stupor,  coma;  normal  pulse  at  first,  but  which  finally  grows  slow, 
full  and  bounding;  and  slow  and  stertorous  breathing.  Delay  is 
dangerous.     The  clot  must  be  removed  and  the  hemorrhage  checked. 

Nearly  always  it  is  the  middle  meningeal  which  is  at  fault.  There 
is  in  consequence  an  extradural  hematoma.  Once  in  a  while,  however, 
the  bleeding  will  be  found  to  proceed  from  a  ruptured  sinus  or  from 
the  pial  arteries  and  there  exists  at  the  same  time  an  injury  to  the 
brain  substance.  There  is,  in  this  case,  an  intradural  or  intracerebral 
hematoma. 

Whatever  the  form  of  compression,  one  is  compelled  to  operate, 
but  he  must  first  get  the  anatomy  of  the  middle  meningeal  artery 
clearly  in  mind. 

The  middle  meningeal,  a  branch  of  the  internal  maxillary,  is  the  size  of 
the  radial,  entering  the  cranial  cavity  at  the  base  of  the  skull,  through  the 
foramen  spinosum.  It  is  embedded  in  the  dura  and  grooves  the  inner  sur- 
face of  the  skull. 

444 


TOPOGRAPHY    OF    Till:     MIDDI.K    Ml   M\«.|    \l  . 


445 


Above  the  level  of  the  zygoma,  the  artery  divides.  The  posterior  brant  li 
the  smaller,  is  directed  upward  and  backward,  and  the  anterior  branch  (Fig. 

325),  the  more  important,  ascends  vertically  to  the  frontoparietal  suture, 
which  it  follows  upward,  passing  a  little  posterior  to  it.  As  it  reaches  this 
future,  it  gives  off  constantly  a  posterior  branch.  The  anterior  branch  is 
accompanied  by  veins  which  occasionally  assume  the  importance  of  a  sinus. 

The  directions  for  trephining  over  the  middle  meningeal  are  quite  definite, 
but  usually  unnecessary  to  regard  in  emergency  surgery,  for  it  is  a  mistake 
not  to  follow  the  exterior  indications  and  guides  furnished  by  the  traumatism. 
Still  one  should  be  able  to  locate  these  points  readily. 

Two  horizontal  and  two  vertical  lines 
arc  employed  to  locate  the  paths  of  the 
two  branches  of  the  middle  meningeal. 
Draw  the  first  (A)  from  the  inferior 
border  of  the  orbit  along  the  zygoma  to 
the  external  meatus.  Draw  the  second 
(B)  from  the  upper  border  of  the  orbit 
backward,  and  parallel  with  the  first,  end- 
ing beyond  the  line  of  the  mastoid.  To 
locate  the  path  of  the  anterior  branch  of 
the  middle  meningeal,  draw  a  perpendic- 
ular line  from  A  upward  from  a  point  cor- 
responding to  the  middle  of  zygoma;  and 
where  it  cuts  B  is  the  point  most  advan- 
tageous for  exposing  the  anterior  branch. 
This  vertical  line  is  about  tw'o  inches  in 

length  or  approximately  equal  to  the  length  of  the  last  two  joints  of  the  index 
finger.  To  locate  the  track  of  the  posterior  branch:  from  the  apex  of  the 
mastoid,  draw  a  second  vertical  line  upward;  its  point  of  junction  with 
B  indicates  the  path  of  the  posterior  branch.  These  lines  may  be  marked 
off  on  the  skin  by  tincture  of  iodine. 

Operation. — Provide,  besides  the  ordinary  instruments,  Rongeur 
forceps,  a  mallet  and  chisel,  or  a  trephine.  Carefully  shave  the  half 
of  the  head  corresponding  to  the  traumatism  or,  even  better,  the  whole 
head.  Sterilize  the  field.  Scrub  with  soap  and  water,  followed  by 
ether,  which  in  turn  is  followed  by  bichloride  solution.  There  must  be 
no  relaxation  in  the  disinfection,  whether  exploration  is  to  be  extensive 
or  not,  for  asepsis  is  the  best  means  of  preventing  a  hernia  of  the  brain. 

General  Anesthesia. — Often  the  sensibility  is  so  benumbed,  the 
patient  so  depressed,  that  anesthesia  is  both  unnecessary  and  danger- 
ous. Chloroform  is  generally  best  for  brain  surgery,  but  ether  is  safer 
in  these  urgent  cases  with  much  shock. 

Incision. — The   incision  will  vary   with   the  conditions.     We   will 


Fig.  325. — Outline  of  the  middle  menin- 
geal artery.      (Veau,  after  Cuneo.) 


446 


URGENT    CRANIECTOMY:    TREPHINING. 


suppose  three  circumstances:  (a)  there  is  an  extensive  skin  wound; 
(b)  there  is  a  bullet  wound;  (c)  there  is  no  wound  of  the  soft  parts. 

(a)  If  there  is  an  extensive  and  ragged  skin  wound,  it  is  better  to! 
enlarge  it  at  once  by  crucial  incision.  This  has  the  advantage  of  being; 
rapidly  done,  but  has  the  disadvantage  that  it  interferes  with  the  blood 
supply  of  the  flaps  (Fig.  326). 

(b)  If  there  is  a  bullet  wound,  make  a  "  U " -shaped  flap  with  the 


Fig.  326. — Depressed  fracture  of  the  skull.     Crucial  incision.      (Veau.) 

bullet  wound  in  the  center,  and  which  retains  its  attachment  below 
the  better  to  conserve  the  blood  supply. 

(c)  If  there  is  no  open  wound,  make  the  same  sort  of  "U  "-shaped 
flap  with  its  pedicle  downward,  over  the  site  of  the  contusion. 

Cut  boldly  to  the  bone  if  it  is  resistant.  If  the  fragments  are 
mobile  under  the  scalp,  proceed  cautiously,  but  do  not  stop  until  on 
the  pericranium.  The  incision  will  often  traverse  a  zone  which  is  con- 
tused and  infiltrated,  the  various  layers  being  indistinguishable. 

If  possible,  form  the  flaps  first  and  then  catch  the  bleeding  points 


EXTRA!   riON    mi     SKI  I  I     \  \<  u.mi 


117 


along  tin-  edges  <•!"  tlu-  tlaps.     In  some  cases  it  may  be  necessary  to 
clamp  a  vessel  In-fore  tin-  incisions  are  completed. 

As  SOOD  as  the  lume  is  reached,  hurriedly  strip  back  the  flaps,  in- 
eluding  the  periosteum.     The  site  of  the  fracture  is  now  ex] 
(Fig.  327).     One  of  two  conditions  presents:  (1)  there  are  d< :  ■ 
fragments  which  must  be  removed,  or  (2)  there  is  a  fissure  without  de- 
pression, but  beneath  the  hone  there  is  a  clot  to  remove  and  a  hemor- 
rhage to  check. 

(1)  The  fragments  are  often  superimposed  in  two  layers  and  those 


Fig.  327. — Stripping  back  the  periosteum  to  expose  the  field  of  fracture.     (Veau.) 


of  the  internal  table  are  usually  the  most  extensive.  In  some  cases 
the  fragments  are  easily  extracted,  but  in  others  the  bony  fragments 
are  so  wedged  in  that  it  is  difficult  to  induce  any  instrument  to  pry 
them  loose.  Failing  in  this,  notch  the  sound  bone  along  the  line  of 
fracture  with  the  chisel,  and  in  this  manner  open  up  a  way  to  introduce 
the  elevator.  Be  careful  not  to  further  bruise  the  brain  in  extracting 
the  fragments,  employing  only  horizontal  traction.  Never  wrench  or 
twist  the  fragments  (Fig.  328). 

The  deeper  fragments  are  usually  adherent  to  the  dura  mater  and, 
if  so,  require  to  be  stripped  loose  before  attempting  extraction. 


448  urgent  craniectomy:  trephining. 

(2)  If  there  exists  merely  a,  fissure,  it  will  be  necessary  to  trephine. 
At  the  possible  site  of  the  hemorrhage,  create  an  orifice  in  the  skull, 
either  with  the  trephine  or  with  mallet  and  chisel. 

Trephine.— (A)  The  ordinary  Gait  trephine  may  be  employed. 
Begin  by  protruding  its  sharp  point  about  1/16  inch  and  boring  it  into 
the  skull  at  the  selected  site.  As  soon  as  the  cutting  edge  of  the  tre- 
phine has  grooved  the  skull,  retract  the  point,  and  proceed  to  deepen 
the  groove  by  rapid  half -rotations  of  the  wrist.  From  time  to  time,  test 
the  groove  with  the  point  of  a  probe  to  be  sure  that  one  side  is  not 


Fig.  328. — Removal  of  the  fragments.     (Veau.) 

cutting  faster  than  the  other.  If  there  is  any  difference,  regulate  the 
pressure  accordingly.  Diminished  resistance  and  increased  blood 
flow  indicate  penetration  of  the  outer  table. 

The  inner  table  is  more  resistant,  and,  when  it  is  reached,  one  must 
proceed  more  cautiously.  When  it  is  judged  that  section  is  complete, 
the  trephine  may  be  removed  and  gentle  effort  made  to  elevate  the 
button.     If  the  bone  is  completely  divided,  the  button  is  easily  removed. 

(B)  Doyens'  instrument  is  in  less  common  use,  but  is  simple  and 
efficient.  It  consists  of  a  brace,  a  perforator,  and  burrs  of  various 
sizes. 


TREPHINING    Willi    MALLEI     VND    CHISE1 


i  19 


Begin  by  attaching  the  perforator  and  drilling  a  shallow  hole,  Bteady- 
ktg  the  brace  with  the  left  hand.  The  instrument  must  always  be 
lept  perpendicular  to  the  skull.  Next  replace  the  perforator  with 
a  burr  and  rapidly  ream  oul  the  opening  begun  by  the  perforator.  As 
before,  one  recognizes  the  approach  to  the  diploe  and  the  inner  table. 
Tin-  burr  pushes  the  dura  before  it  without  injury.  A  quadrilateral  or 
circular  Qap  may  be  outlined  by  additional  openings,  and  the  chisel  or 
|ongeur  used  to  complete  the  section  of  the  Qap. 

((')   The  mallet  and  chisel  may  be  used  and,  while  not  so  efficient 


Pig.  329. — Removal  of  the  clot.     (Veau.) 


as  the  trephine,  will  serve  the  purpose.  Begin  by  cutting  a  narrow 
groove  in  the  skull,  deepening  it  gradually  until  the  inner  table  is 
bached  and  divided.  The  chief  point  to  be  emphasized  is  that  the 
chisel  is  to  be  held  quite  obliquely  to  avoid  concussion  and  unexpected 
penetration. 

Detach  the  dura  malcr.  Whatever  the  means  employed,  the  dura 
is  now  exposed,  and  if  the  opening,  which  should  have  a  diameter  of 
at  least  two  inches,  needs  to  be  enlarged,  the  dura  should  be  deta<  bed 
from  the  edge  of  bone  and  the  chisel  or  rongeur  employed.  Enlarge 
so  as  to  expose  as  nun  h  as  possible  of  the  middle  meningeal  artery. 
29 


45° 


URGENT    CRANIECTOMY:    TREPHINING. 


Treat  the  hemorrhage.  Once  the  cranial  cavity  is  well  exposed, 
the  next  concern  is  the  hemorrhage,  (a)  There  is  a  clot  to  be  re- 
moved; (b)  a  bleeding  vessel  to  control. 

(a)  The  clot  may  be  removed  with  the  finger  or  with  a  dull  curette. 
The  amount  of  the  accumulated  blood  may  be  astonishing,  but  one 
must  work  patiently.  The  clot  must  be  removed  to  the  last  particle; 
remember  that  toward  the  base  there  is  the  greatest  abundance. 
The  white  and  resistant  dura  mater  must  be  exposed  in  every  direction 
(Fig-  329)- 


Fig.  330. — Ligation  of  the  middle  meningeal  artery.      (Veau.) 


(b)  Next  look  for  the  bleeding  vessel.  A  jet  of  blood  may  indicate 
the  proper  point  at  once,  and  the  vessel  is  caught  with  forceps  and  a 
ligature  passed  with  a  needle  (Fig.  330).  If  the  bleeding  point  is  too 
deep,  the  forceps  may  be  left  in  position  for  twenty-four  hours.  More 
often,  perhaps,  the  source  of  the  hemorrhage  cannot  be  definitely  de- 
termined and  as  soon  as  the  compress  is  removed,  the  blood  wells  up 
from  the  bottom  of  the  cavity.  Depressing  the  head,  the  change  in  the 
stream's  direction  may  reveal  its  source  which  is  liable  to  be  the  middle 
meningeal  vein;  it  is  to  be  caught  up  and  ligated  like  the  artery.  If 
the  blood  comes  from  a  sinus,  pack  the  cavity  with  sterile  gauze.  The 
hemostasis  must  be  complete.     If  there  is  only  slight,  yet  persistent 


Mil   B    IKI    \  I  Ml   N  I     01    TRI  I'lllMM..  151 

pozing,  Leave  a  gauze  tampon  far  twenty  four  hours.  Suture  the 
angles  of  the  wound  and  apply  a  dry  dressing. 

Another  case,  more  rare:  The  dura  mater  is  lacerated  and  the  brain, 
more  or  less  contused,  is  exposed.  Catch  the  edges  of  the  dura! 
wound  with  forceps  and,  raising  the  membrane,  gently  wipe  out  the 
bftrts  with  sterile  gauze. 

A  nnic  slit  in  the  dura  may  be  repaired  by  catgut  suture,  but  if  there  is 
loss  of  tissue,  it  is  useless  to  attempt  suture  of  this  inelastic  membrane. 
The  hemorrhage  must  be  eared  for  in  the  manner  already  described. 

Most  trying  are  those  cases  presenting  a  subdural  hematoma.  Tre- 
phining is  completed  and  the  dura  is  exposed,  but  there  is  no  clot. 
Instead,  the  dura,  tense  and  darkened,  bulges  toward  the  orifice. 
Make  a  crucial  incision  in  the  dura,  or  raise  a  flap  with  its  base  above, 
and  wipe  out  the  exudate,  usually  diffused.  Be  very  careful  not  to 
give  additional  injury  to  the  contused  brain  tissue.  Leave  a  strip  of 
sterile  gauze  in  the  wound  for  drainage,  removing  it  on  the  second  day. 

After-trial  mail. — Following  the  operation,  it  may  be  necessary 
to  inject  one  or  two  quarts  of  salt  solution  in  the  first  thirty-six  hours. 
No  alcoholic  stimulants  must  be  used.  Keep  the  patient  absolutely 
quiet,  the  head  slightly  elevated,  and  change  the  dressing  as  often  as 
soiled.  If  sepsis  occurs,  open  up  the  wound.  If  there  is  hernia 
cerebri,  Treves  advises  a  gauze  pad  saturated  with  alcohol  held  on 
under  light  pressure. 

Results. — The  patient  may  die  without  regaining  consciousness, 
owing  to  the  shock  of  the  traumatism,  aggravated  perhaps  by  the 
operation;  for  this  reason,  it  is  absolutely  necessary  to  give  as  little 
chloroform  and  to  do  the  operation  as  rapidly  as  possible. 

He  may  die  the  next  day  from  persistent  hemorrhage.  He  may 
die  between  the  third  and  eighth  day  from  septic  meningitis,  due  to 
infection  from  the  injury  or  the  operation.  Watch  the  course  of  the 
temperature  in  order  to  forecast  sepsis. 

Finally,  he  may  recover,  and  even  then  he  may  develop  a  Jacksonian 
epilepsy,  delayed  perhaps  as  long  as  ten  years.* 

*It  occasionally  happens  thai  the  hemorrhage  occurs  cm  tin-  si<h-  opposite  the 
traumatism.  There  i>  nothing  t<>  do  but  repeat  tin-  trephining  on  tin-  opposite 
tide,  f<>r  the  matter  cannot  be  determined  In-forehand. 


452  URGENT  craniectomy:  trephining. 

FRACTURE   OF   THE   BASE   OF   THE   SKULL. 

It  has  already  been  said  that  the  only  way,  as  certainly  as  may  be, 
to  forestall  infection  in  fracture  of  the  base  is  to  trephine  and  drain, 
leaving  a  permanent  escape  for  microbes  and  their  toxins.  If  there 
is  evidence  of  compression  originating  at  the  base,  the  trephining  is 
even  more  imperative. 

Cushing  recommends  drainage  through  the  lower  temporal  region 
for  the  reason  that  very  much  more  frequently  the  middle  fossa  is 
involved,  the  middle  meningeal  artery  ruptured,  and  the  tip  of  the 
middle  cerebral  lobe  contused. 

Operation. — Make  an  incision  from  the  middle  of  the  zygoma  di- 
rectly upward  to  the  temporal  ridge.  Clamp  the  divided  branches  of 
the  artery.  Divide  the  temporal  fascia  and  split  the  muscle  in  the 
same  line  and  cut  through  to  the  bone.  Strip  back  the  two  halves  of 
the  temporal  by  free  use  of  the  rugine.  If  there  is  a  line  of  fracture, 
or  some  indication  of  pressure,  trephine  accordingly.  Otherwise,  aim 
to  make  the  opening  near  the  junction  of  the  temporal  with  the  great 
wing  of  the  sphenoid.  An  extradural  hemorrhage  may  be  brought 
to  light  and  a  ruptured  middle  meningeal  found.  In  other  cases,  the 
effusion  will  be  reached  only  after  the  dura  is  divided.  The  escape  of 
the  bloody  cerebrospinal  fluid  will  be  favored  by  passing  a  curved 
blunt  dissector  down  under  the  temporal  lobe.  If  the  effusion  is  merely 
serous,  the  wound  may  be  closed;  if  there  is  any  persistence  of  oozing, 
a  strip  of  rubber  tissue  should  be  left  in  the  lower  angle  of  the  wound, 
extending  into  the  cranial  cavity  under  the  temporal  lobe. 

Vincent  (Revue  de  Chirurgie,  Aug.,  1909)  concludes  that  this  inter- 
vention will  reduce  materially  the  sequelae  so  common  to  fracture  of 
the  base  not  treated  by  operation. 

TREPHINING   THE    SUBOCCIPITAL   REGION. 

A  case  of  Ford's  illustrates  this  procedure:  A  man  of  fifty  years 
fell  from  a  street-car,  striking  upon  his  head.  He  was  only  slightly 
dazed;  insisted  he  was  not  hurt  and  walked  home.  An  hour  later,  his 
head  began  to  pain  severely  and  in  the  course  of  a  couple  of  hours  he 
began  to  grow  drowsy  and  so  gradually  lapsed  into  unconsciousness. 


TREPHINING    THE    FRONTAL    REGION.  453 

He  developed  a  divergent  strabismus,  but  bis  pupils  remained  normal 
and  there  were  ao  signs  of  paralysis.    There  were  no  marks  about  his 

head  to  indicate  injury. 

After  twenty-four  hours,  Ford  was  called  in.  He  found  the  patient 
still  unconscious  and  with  the  pulse  and  respiration  of  compression. 
He  was  removed  to  the  hospital  for  operation.  After  the  head  was 
shaved,  a  flatness  was  noticed  below  the  occipital  protuberance,  though 
there  was  no  depression  or  evidence  of  contusion.  It  was  decided,  how- 
ever, to  trephine  over  this  point.  A  semilunar  incision,  convex  up- 
ward, mapped  out  a  flap  with  the  base  downward,  and  the  skull  was 
exposed.  A  stellated  non-depressed  fracture  was  found.  A  trephine 
button  removed  revealed  the  presence  of  a  large  clot.  A  large  area 
of  bone  was  removed  with  rongeur  forceps  and  an  immense  subdural 
clot  cleaned  out  of  the  posterior  fossa.  A  strip  of  iodoform  gauze  was 
left  for  drainage.     Uninterrupted  recovery. 

We  might  add  that  in  all  cases  of  head  injury  followed  by  compres- 
sion symptoms,  but  in  which  there  is  no  evidence  of  rupture  of  the 
middle  meningeal  artery  nor  any  focal  symptom,  the  suboccipital 
operation  is  preferable  to  the  subtemporal.  It  will  give  easier  and 
safer  access  and  more  efficient  drainage. 

TREPHINING   THE   FRONTAL   REGION. 

A  case  reported  by  Axtell,  of  Bellingham,  Wash.  (Northwest 
Medicine,  Nov.,  1908),  illustrates  the  procedure: 

A  laborer  received  a  violent  blow  from  a  cable  hook  above  the  left 
eye.  In  spite  of  the  severity  of  the  injury,  the  man  walked  a  mile  to 
camp.  Traveling  by  a  logging  train,  by  boat,  and  by  street  car,  nine 
hours  later  he  reached  the  hospital,  showing  no  indication  of  collapse 
till  he  reached  his  destination.  He  had  a  marked  depression  over 
the  left  orbit,  a  swollen  eyelid,  and  a  protruding  eyeball. 

A  semicircular  incision  extending  from  the  bridge  of  the  nose  to  the 
external  angular  process  exposed  the  shattered  supraorbital  ridge. 
The  orbital  plate  of  the  frontal  bone  was  broken  into  fragments  and 
a  large  blood  clot  was  found  filling  the  upper  and  back  portion  of  the 
socket,  forcing  the  eye  onto  the  cheek. 


454  urgent  craniectomy:  trephining. 

Three  lines  of  fracture  extended  from  the  supra-orbital  ridge  across 
the  frontal,  which  was  depressed  in  several  places.  The  fragments 
of  the  orbital  plate  were  removed;  and,  on  removing  the  depressed  por- 
tions of  the  frontal,  the  dura  mater  and  subjacent  portion  of  the  brain 
were  found  mangled.  The  brain  tissue  was  trimmed  out,  the  dura 
adjusted,  and  the  fragment  of  the  supra-orbital  ridge  that  remained  at- 
tached to  the  pericranium  was  so  turned  and  fastened  that  it  covered 
the  supra-orbital  ridge  that  had  been  destroyed.  This  was  retained 
in  place  by  sutures  passed  through  the  skin  flap  which  was  drawn 
into  place.  The  recovery  was  uninterrupted,  and  a  year  after  there 
was  nothing  to  indicate  the  injury  but  a  puffiness  of  the  upper  lid. 

Trephining  for  Gunshot  Wounds. — Every  case  of  gunshot  wound 
of  the  skull  must  be  explored;  though,  of  course,  no  trephining  is 
necessary  unless  there  is  perforation  or  unless  there  are  evidences  of 
gunshot  fracture  without  perforation. 

When  it  has  been  determined  that  there  is  perforation,  raise  a  flap 
with  the  bullet  wound  in  the  center,  as  has  been  already  described. 
The  flap  must  be  larger  than  the  possible  trephine  opening  in  the 
skull.  Enlarge  the  opening  in  the  skull  with  trephine,  chisel  and 
mallet,  or  with  rongeur  forceps.  Remove  all  fragments  of  bone  and 
foreign  matter,  wipe  out  the  dural  and  cerebral  wounds  with  sterile 
gauze.  Be  patient  and  persistent  in  this  cleansing.  Do  not  explore 
the  bullet  track  or  attempt  to  remove  the  bullet  unless,  of  course,  it 
is  within  easy  reach. 


CHAPTER  V. 

MASTOID  ABSCESS. 
The  tympanum,  and  likewise  its  accessory  cavities,  are  normally 

sterile,  hut  there  are  two  highways  by  which  infection  may  reach  this 
site,  the  Eustachian  tube  and  the  external  auditory  canal.  The 
Eustachian  canal  is  the  much  more  common  route,  the  infection  hr^t 
gaining  a  foothold  in  the  mucous  membrane  of  the  naso-pharynx, 
so  that  an  inflammation  of  the  mucosa  of  the  middle  ear  is  often  only 
a  step  further  in  the  ordinary  pharyngeal  catarrhal  process. 

Finally,  the  catarrhal  inflammation  may  become  a  purulent  one, 
in  either  case,  running  an  acute  or  chronic  course.  Again,  the  pyo- 
genic germ  will  not  long  limit  its  operation  to  the  tympanum;  but 
eventually  invades  the  pneumatic  spaces  adjacent,  the  antrum  and 
mastoid  cells;  and  then  there  may  develop  a  mastoid  abscess,  a  con- 
dition full  of  potential  danger.  The  thin  roof  of  the  middle  ear  is  the 
dividing  line  between  the  posterior  and  middle  cerebral  fossa?,  and 
through  it  infection  may  reach  the  cerebellum  or  the  middle  lobe 
of  the  cerebrum:  meningitis,  epidural,  cerebral,  or  cerebellar  abscess 
is  the  immediate  result. 

The  mastoid  cells  are  separated  from  the  lateral  sinus  by  a  bony 
partition,  so  that  through  the  small  venous  channels  or  by  necrosis 
of  the  bony  wall,  infection  may  reach  the  sinus.  Finally,  general 
infection  and  sinus  thrombosis  may  ensue,  followed  perhaps  by  metas- 
tatic abscess. 

These  are  the  actual  dangers  of  mastoid  abscess  and  one  can  never 
tell  how  fast  the  pathological  process  may  extend,  aided  by  bone  ero- 
sion or  by  the  escape  of  the  infectious  matter  through  apertures  in 
the  bone  or  by  the  blood  vessels  and  Lymphatics. 

Acute  purulent  mastoiditis,  then,  is  an  emergency,  and  every  doctor 
should  feel  himself  prepared  to  trephine  the  mastoid  if  it  becomes 
his  duty,  and  it  is  his  duty  if  no  one  more  .skilled  is  at  hand. 

455 


456  MASTOID   ABSCESS. 

1v  How  shall  one  recognize  this  emergency? 

The  pain,  sleeplessness,  prostration,  fever,  together  with  the  history 
of  the  case,  point  with  a  great  degree  of  probability  to  the  nature  of 
the  trouble.  Now,  if  the  examination  adds  certain  other  signs  to 
these  symptoms,  the  indications  for  intervention  are  definite: 

(1)  You  find  the  upper  and  posterior  quadrant  of  the  ear  drum 
(Shrapnell's  membrane)  bulging  and  perhaps  the  superior  and  poste- 
rior walls  of  the  canal  are  swollen. 

(2)  You  find  persistent  tenderness  over  the  mastoid  process. 

(3)  You  may  observe  that  a  previously  free  discharge  has  suddenly 
diminished  and  this  is  an  added  warning  that  delay  is  dangerous. 

To  repeat,  the  cardinal  symptoms  are  pain,  redness,  swelling,  bulg- 
ing of  the  drum,  and  fever.     The  first  thing  to  do  is  a  paracentesis. 

PARACENTESIS. 

Douche  the  auditory  canal  gently  with  warm,  sterile  water;  co- 
cainize the  canal  with  a  10  per  cent,  solution  and  wait  five  or  ten 
minutes.  With  the  otoscope,  expose  the  drum  and  locate  the  bulging 
area.  Puncture  it  with  a  small  pointed  bistoury  making  an  incision 
three  or  four  millimeters  long,  downward  and  forward. 

There  is  nothing  to  fear.  Even  if  the  drum  has  spontaneously 
ruptured,  it  is  often  an  advantage  to  enlarge  the  opening.  Usually 
a  few  drops  of  pus  escape.     Follow  with  irrigation. 

If,  at  the  end  of  twenty-four  hours,  the  symptoms  have  not  subsided, 
proceed  without  further  delay  to  trephine  the  mastoid. 

Operation. — The  operation  is  easy  and  without  much  danger  if  one 
but  knows  the  anatomy  (Fig.  331).  The  sigmoid  sinus  is  more  shallow 
in  children  than  adults.  Recall  the  situation  of  the  spine  of  Henle, 
the  facial  nerve,  and  the  lateral  sinus.  The  spine  of  Henle  marks  the 
upper  limit  of  the  external  meatus;  one-quarter  inch  above  it  is  the 
middle  cerebral  fossa;  the  mastoid  antrum  is  one-half  inch  posterior. 

Shave  the  temporo-parietal  region  and  scrupulously  prepare  the 
field.     General  anesthesia  is  indispensable. 

Special  instruments  necessary  are  a  Macewen  seeker,  a  chisel  (one 
centimeter  wide),  a  small  gouge,  mallet,  curette,  curved  periosteal 
elevator,  and  probe. 


EU  i  \u>>\    "i     mi     i  \ii  i'\i       r  i        K)    mi     MASTOID    PRO(  i  5S.      |" 


PlG.   331. — Landmarks  of  the  mastoid.     The  square  represents  the  area  to  be  trephined 
the  dotted  lines  the  course  of  the  lateral  sinus.     (Veau.) 


Fig.  332. — Incision  for  mastoid  operation.      (Veau.) 


458 


MASTOID   ABSCESS. 


Incision  (Fig.  332). — Begin  at  the  apex  of  the  mastoid  and  follow 
the  curve  of  the  external  ear  to  the  level  of  its  attachment  above.  This 
incision  reaches  to  the  bone;  and,  when  operating  on  children,  be  care- 
ful not  to  cut  through  the  bone.  Catch  the  bleeding  vessels  in  the 
gaping  wound.  Rapidly  denude  the  bone,  an  undertaking  some- 
what difficult  below  where  the  sterno-mastoid  is  attached  (Fig.  333). 

Introduce  a  sound  into  the  external  auditory  canal  to  determine 
its  direction.     Expose  the  spine  of  Henle. 


Fig.  333. — Denuding  the  mastoid  with  the  rugine.     (Veau.) 

Trephine.  Start  the  chisel  vertically  five  millimeters  behind  the 
meatus;  two  or  three  slight  blows  of  the  mallet  will  be  sufficient. 
In  a  child,  a  bistoury  may  be  used.  Make  the  second  trace  with  the 
chisel  horizontal  and  on  a  level  with  the  spine  of  Henle.  The  third 
is  parallel  with  the  second,  and  finally  the  fourth,  parallel  with  the 
first,  completes  the  outline  of  chip.  This  fourth  line  of  section  is 
in  the  danger  area,  nearly  over  the  lateral  sinus.  In  making  it,  hold 
the  chisel  obliquely  instead  of  vertically  as  in  the  first  (Fig.  334).  By 
slight  and  rapid  blows,  remove  this  chip. 


EXPOSING    nil     MASTOID  CI  LLS. 

If  this  does  not  expose  the  cells,  deepen  the  opening  carefully  with  the 
gouge.    Pus  will  often  be  found  at  the  first  incision  into  the  bony  wall. 


pIG   334 — Outlining  the  chip  of  bone  to  be  removed. 


15. — Exposing-the  lower  mastoid  cells.     (I  KM.) 


Introduce  a  seeker  or  blunt  probe,  which  will  locate  the  various 
cavities  and  canals  leading  to  the  cells  of  the  mastoid  and  antrum. 


460  MASTOID   ABSCESS. 

Their  coverings  are  then  chipped  off,  or  they  may  be  merely 
curetted. 

Chisel  below  first  (Fig.  335),  and  then,  with  the  guide,  locate  the 
posterior  limit  of  the  cells  and  chisel  off  the  bone  lying  over  the  point 
of  the  guide.  A  trough  may  be  trephined  downward  toward  the  tip. 
Remember  that  posteriorly  there  is  the  lateral  sinus  (Fig.  336).  Do 
not  stop  until  all  the  cells  are  freely  exposed. 

When  the  mastoid  cells  are  thus  opened  up,  it  remains  to  expose 
the  antrum  (Fig.  337).     It  lies  in  the  direction  upward  and  forward  at 


Fig.  336. — Exposing  the  posterior  cells.     The  lateral  sinus  must  be  avoided.      (Veau.) 

what  seems  a  considerable  depth,  one  to  three  centimeters.  Locate 
the  cavity  with  the  guide,  and  enlarge  freely.  The  mastoid  cells  and 
the  antrum  are  now  a  single  cavity.  Carefully  curette  the  necrosed 
bone  and  fungosities,  but  be  very  careful  when  curetting  over  the 
posterior  wall,  for  the  lateral  sinus  may  be  exposed.  Throughout 
the  operation,  one  may  be  disturbed  by  the  hemorrhage,  always  con- 
siderable, and  it  will  be  necessary  to  sponge  continually,  for  it  is  in- 
dispensable that  one  see  what  he  is  doing. 

Certain  accidents  may  occur  in  the  course  of  the  operation. 

(1)  The  lateral  sinus  may  be  wounded,  immediately  recognized 
by  the  excessive  hemorrhage;  but  do  not  be  perturbed,  for  it  is  easy  to 


in.I1  k\    TO    mi     PACT  \l.    M  K\  i  . 


I'm 


Irrest  the  bleeding.  Pack  the  point  or  apply  hot  moist  applications 
with  sterile  gauze  and  continue  the  operation.  If  you  find  thrombosis, 
it  will  he  necessary  to  open  the  sinus. 

(2)  The  cranial  cavity  may  he  opened,  hut  neither  is  this  j » ;  1  r t i <  - 
ularly  serious.  However,  you  should  avoid,  if  possible,  an  injury 
to  the  meninges,  for  there  is  danger  of  infection.  Chisel  discreetly, 
therefore,  at  the  upper  angle  of  the  opening. 

If  you  do  wound  the  dura,  disinfect  and  tampon,  hut  do  not  attempt 
suture.     If  is  scarcely  possible  at  that  depth  in  a  cavity  so  narrow. 


Fig.  337. — The  operation  completed,  the  guide  is  in  the  antrum.     (Veau.) 


The  facial  nerve  may  get  in  the  way,  and  if  wounded,  that  is  indeed 
a  serious  matter,  for  you  can  do  nothing  to  remedy  it.  It  is  deeply 
situated  and  if  you  follow  the  guide,  you  are  scarcely  likely  to  reach  it 
with  the  gouge.  It  is  almost  certain  to  be  injured  if  the  mastoid  is 
fractured  in  the  course  of  the  trephining,  and  this  will  happen  if  the 
mallet  and  chisel  are  recklessly  used.  Injur}-  to  the  facial  nerve  is 
really  the  one  danger  of  the  operation.  Close  approach  is  indicated 
by  twitching  of  the  facial  muscles. 

Dressing  and  Subsequent  TrcatHicnt.—ParUiiUy  suture  the  wound  and 
pack  with  iodoform  gauze.  The  dressings  are  as  important  as  the 
operation.     If  neglected,  a  fistula  may  form  or  the  suppuration  may 


462  MASTOID   ABSCESS. 

recur.  Instruct  the  patient  that  repair  may  require  six  to  eight  weeks, 
or  longer. 

On  the  second  day  after  the  operation,  remove  the  gauze  and  irrigate 
with  warm  sterile  water,  dry  carefully  and  repack  methodically  so 
that  all  the  diverticula  are  filled.  They  must  not  be  allowed  to  close 
over.     Granulation  from  the  bottom  is  indispensable. 

Change  the  dressing  every  other  day.  Repress  excessive  granula- 
tion with  tincture  of  iodine  or  nitrate  of  silver. 

Keep  the  patient  in  bed  for  one  week;  keep  the  bowels  open,  and 
regulate  the  diet. 


CHAPTER  VI. 

GENERAL  TECHNIC  OF  LAPAROTOMY. 

Since  so  many  urgent  conditions  require  a  laparotomy,  every  do<  tor 
.should  be  familiar  with  the  general  technic  of  the  procedure  without 

regard  to  any  particular  purpose  for  winch  the  abdomen  may  be 
opened. 

For  the  purpose  of  ready  review,  the  various  difficulties 
and  their  management  and  the  after-treatment  are  briefly 
outlined. 

Preparation  of  the  Patient. — Whenever  possible,  the  patient  should 
he  under  a  preliminary  treatment  for  two  or  three  days  in  order  that 
the  bowels  may  be  thoroughly  cleansed,  the  field  of  operation  sterilized 
with  certainty,  and  the  functions  of  the  organs  noted.  In  emergency 
work,  these  details  cannot,  of  course,  be  so  definitely  regulated,  but  to 
omit  any  of  them  is  a  handicap. 

To  have  the  bowels  emptied  by  castor  oil  and  enemata  is  the  best 
prophylaxis  against  meteorism,  which  may  be  a  source  of  embarrass- 
ment to  the  operator  in  the  course  of  the  operation,  and  a  source  of 
discomfort  and  perhaps  danger  to  the  patient  subsequently. 

However  urgent  the  operation  may  be,  the  sterilization  of  the  field 
must  be  definite,  even  though  the  methods  be  abbreviated.  To  scrub 
with  soap  and  water,  shave,  wash  with  alcohol  or  ether  to  remove 
the  oils,  and  finally  bathe  with  bichloride  solution  and  cover  with 
bichloride  compresses  until  ready  to  make  the  incision  is  to  realize 
a  practical  asepsis  so  far  as  the  skin  is  concerned;  or  the  sterilization 
may  be  even  more  rapidly  accomplished  by  washing,  shaving,  and  dry- 
ing the  skin,  and  then  painting  with  tincture  of  iodine. 

To  have  a  definite  knowledge  of  the  patient's  temperament,  of  the 
action  of  his  circulation  and  respiratory  organs  and  of  his  kidneys 
is  to  forestall  many  difficulties  and  dangers.     At  least  a  full  stomach 

463 


464  GENERAL    TECHNIC    OF    LAPAROTOMY. 

should  be  washed  out,  and  the  bladder  emptied  before  the  operation  is 
begun. 

Incision. — The  operator  may  stand  on  either  side.  It  is  preferable 
to  stand  to  the  patient's  right  and  cut  from  above  toward  the  pubes, 
supposing  a  median  laparotomy. 

The  skin  and  subcutaneous  fatty  tissues  are  divided  first.  Clamp 
the  small  vessels  and  gently  sponge.  In  the  case  of  abscess  and 
chronic  inflammation,  the  bleeding  is  likely  to  be  rather  free  but  never 
dangerous. 

The  aponeurosis,  when  possible,  should  be  divided  in  the  linea  alba, 
because  the  bleeding  will  be  less  and  the  access  to  the  peritoneum 
readier.  On  either  side  of  the  middle  .line  the  incision  opens  into  the 
sheath  of  the  rectus,  whose  inner  border  should  be  displaced  to  the 
outer  side  or  its  fibers  split.  The  edges  of  this  fascia  should  be  caught 
with  forceps  in  order  to  be  more  readily  recognized  in  the  course  of 
repair. 

The  peritoneum  is  now  exposed,  covered  usually  by  fatty  areolar 
tissue,  more  or  less  thick.  Catch  up  a  fold  of  it  between  two  forceps 
and  make  a  small  opening  with  either  knife  or  scissors,  using  caution 
not  to  cut  into  the  bowel  or  omentum. 

The  lips  of  the  peritoneal  wound  are  controlled  with  forceps  which 
are  to  he  left  attached;  and  now  enlarge  the  opening  in  either  direction, 
using  the  finger  as  a  guide  and  as  a  protection  to  the  bowel.  Approach- 
ing the  pubes,  guard  against  wounding  the  bladder,  of  which  there  is 
no  danger  if  it  has  been  previously  emptied.  In  any  event,  it  can  be 
readily  located  by  the  sense  of  touch. 

Protect  the  Cut  Surfaces. — When  the  peritoneum  is  opened  to  the 
necessary  extent,  apply  two  wide  compresses  of  gauze,  so  as  to  com- 
pletely cover  the  incisions  and  attached  forceps,  tucking  the  edge  of 
each  compress  under  either  side  of  the  peritoneum.  This  is 
to  diminish  the  chances  of  infection  and  to  prevent  bruising  the 
peritoneum. 

In  like  manner,  and  for  the  same  purpose,  the  parts  that  are  to  be 
dealt  with  are  packed  off  from  adjacent  structures  with  large  com- 
presses which  are  not  only  more  efficient  than  small  ones,  but  also  are 
less  likely  to  be  lost  within  the  peritoneal  cavity.     The  surgeon  or  a 


ill  MORRB  M-\:    l\    I  tPAROTOlft  .  f>5 

lesponsible  assistant  must  always  know  how  many  compresses  arc 
brought  into  use,  and  they  must  be  accounted  for  before  the  cavity  is 
closed. 

Management  of  Peritoneal  Adhesions.    The  novice  and  even  the 
mosl  practised  surgeon  may  experience  the  greatest  difficulty  in  sepa 
rating  adherent  organs,  their  peritoneal  surfaces  glued  together  as 
the  result  of  inflammation. 

In  the  ease  of  recent  adhesions,  they  are  soft  and  easily  broken. 
In  other  cases,  they  consist  of  hands  which  need  only  be  divided 
with  scissors;  but  anally  they  may  hind  together  Large  anas  of  adjacent 
structures  so  as  often  to  render  them  indistinguishable. 

Even  here  with  a  little  patience  one  may  often  find  a  plane  of  cleavage, 
especially  if  the  parietal  peritoneum  is  involved.  If  the  organ  cannot 
be  separated  from  the  parietal  peritoneum,  a  segment  of  this  latter  is 
to  be  cut  out  and  left  attached  to  the  viscus  concerned.  In  the  case 
of  the  omentum  it  is  to  be  ligated  twice  and  cut  between.  In  the  case 
of  the  intestine,  the  greatest  care  must  be  used  not  to  break  through  its 
wall. 

In  general,  intestinal  adhesions  discovered  in  the  course  of  operation 
are  not  to  be  broken  up  except  as  they  interfere  with  the  work  in  hand 
or  are  likely  to  obstruct  the  bowel. 

If  no  plane  of  cleavage  can  be  found,  then  the  other  organ  involved 
must  be  deprived  of  its  peritoneal  coat  to  protect  the  gut.  If  the  sur- 
face of  the  intestinal  loop  is  left  raw  after  the  separation,  the  Lembert 
suture  should  be  employed.  If  the  bowel  wall  is  torn  through,  it  must 
be  repaired  by  two  rows  of  suture:  a  through -and -through  and  a  Lem- 
bert suture. 

Hemorrhage. — The  visceral  blood  supply  is  complex;  to  have  its 
anatomy  clearly  in  mind  is  a  great  advantage  in  hemorrhage  from 
larger  vessels.  To  locate  the  vessel  at  fault,  to  clamp  it  and  ligate 
quickly,  speeds  the  operation.  Capillary  oozing  can  generally  be  con- 
trolled by  a  few  moments'  application  of  hot  compresses.  A  compress 
wet  with  alcohol  will  often  promptly  check  free  bleeding.  If  the 
oozing  is  persistent  at  the  end  of  the  operation  and  measures  applied 
have  failed  to  check  it,  the  abdomen  must  not  be  closed  without 
drainage. 
3° 


466  GENERAL    TECHNIC    OF    LAPAROTOMY. 

To  insure  against  recurrence  of  hemorrhage  as  well  as  to  prevent 
infection  and  adhesions,  all  raw  surfaces  should  be  covered  oven 
with  a  peritoneal  coat.  It  is  never  desirable  and  seldom  necessary! 
to  leave  a  denuded  area  in  the  peritoneal  cavity.  Use  of  the  Lembert 
.suture  and  of  the 'free  omentum  enables  one  to  obliterate  them.  Such : 
as  must  be  left  should  be  sprinkled  with  aristol. 

Drainage. — The  old  dictum,  "When  in  doubt,  drain,"  does  not  apply 
with  such  force  to  laparotomy  as  formerly.  In  fact,  there  are  those 
bold  enough  to  say,  "When  in  doubt  do  not  drain."  Still  it  must  be i 
admitted  that,  in  spite  of  drawbacks,  drainage  is  a  real  safeguard 
against  infection.  One  should  drain,  then,  when  any  septic  process 
is  present  or  is  likely  to  develop,  as  in  the  case  of  perforating  wounds 
of  the  intestine. 

Drainage  must  be  employed  whenever  it  is  impossible  to  control 
bleeding  from  raw  surfaces.  If  there  is  no  infective  process  present 
in  the  peritoneal  cavity,  if  there  is  no  obvious  reason  for  any  to  develop 
later,  the  abdomen  is  to  be  closed  completely. 

The  preferable  method  of  draining  the  abdominal  cavity  is  by 
rubber  tubes.  This  is  the  only  method  available  if  pus  is 
present.  If  the  main  object  is  to  get  rid  of  blood,  then  the  tube 
should  contain  a  wick  of  gauze  which  should  rest  upon  the  oozing 
surface  that  it  may  serve  the  double  purpose  of  hemostasis  and 
drainage. 

As  soon  as  the  oozing  has  ceased  the  gauze  wick  is  to  be  withdrawn 
while  the  tube  remains.  The  tubal  drains  are  to  be  removed  as  soon 
as  the  danger  of  sepsis  is  passed. 

Repair  of  the  Abdominal  Wall. — Suppose  the  operation  complete. 
The  final  inspection  of  ligatures  and  sutures  is  made,  the  cavity  is 
wiped  out,  the  compresses  are  removed  and  counted,  the  vessels  in 
the  abdominal  wall  that  were  clamped  are  ligated,  if  necessary,  and 
repair  of  the  abdominal  wall  is  begun. 

The  peritoneum,  to  which  the  forceps  still  remain  attached,  is  pulled 
up  into  view.  If  the  Trendelenburg  position  has  been  used,  the  table 
is  now  brought  to  the  horizontal;  the  intestines  are  brought  back  into 
place,  the  omentum  spread  out  over  them,  and  a  compress  applied  to 
protect  the  bowel  while  the  peritoneum  is  repaired  with  a  continuous 


\ii  n;   ril   \  i  \n  \  r   in     I  APAR0T01IY.  l'>7 

Wo.  o  catgut  suture.    The  compress  is  withdrawn  before  the  last  two 
or  three  stit<  hes  arc  passed. 
The  aponeurosis  and   muscles   are   now   repaired   with   continuous 

clironiit  gut  suture. 

The  skin,  finally,  is  to  be  repaired  with  interrupted  silkworm-gut 
sutures,  passing  some  of  them  deep  enough  to  include  the  muscles 
and  aponeurosis  so  as  to  obliterate  any  dead  spaces.  If  coaptation  is 
lot  perfect,  a  few  superficial  catgul  sutures  may  Ik-  used  a-  accessary. 
One  may  close  the  skin  simply  by  the  continuous  catgut  or  chromic 
gut  suture  or,  as  many  prefer,  by  the  subcuticular  stitch. 

Of  course,  if  drainage  has  been  employed,  the  closure  cannot  be 
complete,  though  the  suturing  is  to  be  carried  close  up  to  the  tube.  In 
case  great  haste  is  required,  the  abdomen  may  be  closed  by  a  feu- 
through -and-through  sutures  of  silkworm-gut. 

After-treatment. — In  the  uncomplicated  case,  the  after-treatment  is 
simple.  The  patient  is  put  to  bed  where  he  can  get  plenty  of  fresh  air 
and  hot-water  bottles  put  to  his  feet.  As  he  recovers  from  the  anes- 
thetic, he  is  given  water  cautiously  for  the  first  twenty-four  hours. 
After  that,  liquid  nourishment  should  be  given  in  small  quantities 
at  frequent  intervals.  The  bowels  should  be  moved  on  the  second 
day  by  a  light  soapsuds  enema. 

It  is  rare,  however,  that  these  patients  do  not  have  some  complica- 
tion. If  there  was  much  shock  or  much  hemorrhage,  or  if  the  anes- 
thesia was  prolonged,  give  normal  solution  by  one  of  the  three  methods, 
hot  coffee  by  the  rectum  and  whatever  cardiac  stimulant  may  seem  in- 
dicated, strychnia,  brandy,  or  camphorated  oil. 

If  the  pain  is  severe,  small  doses  of  morphia  hypodermic  ally  should 
be  given  until  the  patient  is  comfortable. 

If  there  is  much  nausea,  try  a  glass  of  warm  soda-water  which  will 
probably  be  thrown  up,  and  thus  washes  out  the  stoach.  If  the 
nausea  is  quite  severe,- wash  out  the  stomach  and  put  the  patient  in  a 
half-sitting  position.  If  the  thirst  is  extreme  along  with  vomiting, 
enemas  of  normal  salt  solution  give  the  most  relief. 

Sometimes  5—1 5  minims  of  aromatic  spirits  of  ammonia,  given 
hypodermic  ally,  tend  to  relieve  the  nausea,  while  acting  as  a  diffusible 
stimulant. 


468  GENERAL    TECHNIC    OF    LAPAROTOMY. 

If  there  is  much  flatulence  or  meteorism,  give  minute  doses  of  calomel 
and  empty  the  bowel  with  soapsuds  enema.  If  this  does  not  give 
relief,  the  enema  consisting  of  two  ounces  of  Epsom  salts  and  glycerin 
and  one  ounce  of  turpentine  may  be  employed. 

A  special  line  of  treatment  is  required  if  postoperative  ileus  develops 
(see  page  517). 


CHAPTER   VII. 
LAPAROTOMY  FOR  TRAUMATISM. 

The  indications  for  laparotomy  following  traumatism  are  as  follows: 
i.  Perforating  gunshot  wounds. 

2.  Perforating  stab  wounds  likely  to  have  wounded  a  viscus. 

3.  Contusions  of  the  abdomen  presenting  symptoms  of  dangerous 
lesions  of  abdominal  viscera  or  vessels;  not  always  definite,  but  operate 
at  once  if  you  find  these  appearances  following  contusions: 

(a)  The  abdominal  walls  are  resistant  some  distance  from  the  in- 
jury; a  progressive  meteorism  reaching  the  hepatic  region;  dullness 
over  the  iliac  fossae  or  the  flanks,  indicating  hemorrhage. 

(b)  The  pulse  is  weak  and  rapid,  and  growing  worse. 

(c)  The  general  condition  of  the  patient  is  alarming,  pallor,  pain, 
excitement  or  delirium,  subnormal  temperature. 

But  whether  it  be  an  open  wound  or  a  contusion,  do  not  wait  for 
the  symptoms  of  peritonitis,  for  it  will  then  likely  be  too  late.  The 
operation  is  delicate  and  dangerous  in  the  hands  of  the  unskilled,  and 
yet  the  patient's  life  depends  upon  it.  There  is  no  time  to  send  for  a 
specialist  unless  he  is  right  at  hand,  and,  as  Veau  says,  it  is  better  for 
the  patient  to  be  operated  on  early  by  an  inexperienced  surgeon  than 
to  be  operated  on  too  late  by  the  best  surgeon  in  the  land.  It  is  an 
intervention  in  which  one  never  knows  what  he  is  going  to  find. 

The  steps  of  the  operation  are: 

(1)  A  laparotomy. 

(2)  Search  for  the  licmorrhage  if  there  is  blood  in  the  abdomen. 

(3)  Search  for  visceral  injuries. 

General  anesthesia  is  indispensable,  and  ether  is  preferable  unless 
compelled  to  operate  in  close  quarters  by  lamp  light.  Every  precau- 
tion must  be  taken  not  to  aggravate  shock;  the  limbs  should  be  wrapped 
and  the  chest  protected.     The  whole  anterior  abdominal  wall  must  be 

469 


47° 


LAPAROTOMY   FOR   TRAUMATISM. 


sterilized.-    Be  prepared  for  normal  salt  injections,   often  necessary 
throughout  the  operation. 

(i)  Laparotomy  Whatever  be  the  site  of  the  wound  or  contusion, 
make  an  incision  in  the  middle  line;  below  the  umbilicus,  usually; 
above,  if  the  injury  points  to  the  epigastrium.  The  incision  at  first 
should  be  about  three  inches  long.  It  may  be  necessary  to  extend  it. 
Divide  the  skin  and  fatty  tissues  and  catch  up  the  bleeding  vessels. 
Open  the  sheath  of  the  rectus  and  look  for  the  linea  alba,  but  if  not 
readily  found,  go  through  the  muscle;  it  does  not  greatly  matter. 

Divide  the  transversalis  fascia  and 
expose  the  subperitoneal  fatty  tissue. 
It  may  be  quite  thick. 

The  peritoneum  will  probably  not 
be  recognized  by  its  appearance,  but 
rather  by  observing  the  tissues  gone 
through.  It  is  usually  bulging.  One 
may  be  able  to  see  free  blood  in  the 
cavity  by  reason  of  its  transparency. 

Catch  up  the  peritoneum  with  dis- 
secting forceps  and  incise  the  cone 
thus  formed,  with  the  cutting-edge  of 
the  scalpel  turned  away  from  the  ab- 
dominal cavity,  that  the  bowel  may  not 
be  wounded  (Fig.  338).  Enlarge  the 
small  opening  thus  created,  and  direct 
the  assistant  to  seize  the  lips  of  the  peritoneal  wound  with  forceps. 

Pay  no  attention  to  the  blood  which  may  pour  out,  but  proceed 
rapidly  to  elongate  the  peritoneal  wound  with  the  scissors,  protecting 
the  bowel  with  the  left  index  finger  (Fig.  339).  Remember  the  peri- 
toneum envelops  the  bladder,  so  do  not  open  the  peritoneum  down 
to  the  pubes,  although  the  skin  wound  should  be  carried  thus  far  in 
order  to  give  the  best  view  (Fig.  340). 

Carefully  catch  up  the  lips  of  the  peritoneal  wound  with  forceps 
which  may  also  serve  as  retractors;  such  control  of  the  peritoneum  will 
also  facilitate  its  suturing  at  the  end  of  the  operation.  It  may  now 
be  necessary  to  push  the  anesthesia  a  little  if  there  is  much  resistance. 


Fig.   338. — Incising  the  fold  of 
peritoneum.      (Guibe.) 


CONTKnl     ill      I  III      III   \|o|.:  I'll  V.I 


17' 


(2)  Locate  and  check  the  hemorrhage.  I>"  nol  be  in  a  hurry  to 
put  ;i  hand  in  the  cavity  bul  observe  closely,  sponging  gently.  The 
character  oi  the  Quids  may  be  helpful  in  diagnosis.  The  examining 
finger  may  detect  lesions,  or  the  injured  viscera  may  push  up  into  the 
wound. 


Fig.  339. — Enlarging  the  peritoneal  opening  with  the  scissors  on  the 
index  finder  to  guide.      (Guibe.) 


The  hemorrhage  may  come  from  the  following:  (a)  omentum; 
(h)  mesentery;  (c)  the  vascular  organs,  liver,  spleen,  kidney;  (d) 
the  vessels  of  the  posterior  abdominal  wall. 

(a)  The  great  omentum  should  be  gently  lifted  Out  of  the  cavity. 
It  may  contain  a  hematoma  and  the  divided  vessels  be  hard  to  find. 


472 


LAPAROTOMY   FOR   TRAUMATISM. 


Tie  them  with  No.  2  catgut.  If  the  omentum  is  torn  and  lacerated, 
resect  the  injured  portion  (Fig.  414).  It  may  be  split;  the  large  vessels 
opened  must  be  tied;  the  small  will  be  controlled  by  the  continuous 
suture,  which  should  reunite  the  edges  of  the  wound.     If  the  omentum 


Fig.  340. — Enlarging  the  opening  toward  the  pubes,  the  bladder  must 
not  be  wounded.     (Guibe.) 

is  detached  from  the  greater  curvature,  the  stomach  should  be  exposed, 
and  the  omentum  sutured  thereto. 

(b)  The  hemorrhage  from  the  mesentery  may  be  arrested  in  the 
same  manner,  though  one  may  not  find  it  until  in  the  course  of  in- 
specting the  gut.  Mesenteric  wounds  often  exist  without  visceral 
injury.     In  suturing  the  tear,  the  needle  must  be  passed  close  to  the 


rREATMENT  OF  WOUNDS  01     mi     INTESTINE.  173 

gdges  of  the  wound  s<>  thai  qo  vessel  may  be  wounded  or  included  in 
the  tie. 

It  its  attachment  to  the  bowel  is  disturbed  for,  say,  more  than  three 
itches  or  it'  it  is  accessary  to  tie  a  branch  as  large  as  the  radial,  the 
Integrity  of  the  corresponding  section  of  gut  is  compromised  and  it 
will  be  advisable  to  resect.  If  unable  to  d<>  that,  treat  it  as  the  doubt- 
ful bowel  is  treated  in  strangulated  hernia  (see  page  539). 

(c)  If  the  hemorrhage  proceeds  from  a  wound  of  the  liver,  spleen, 
or  kidney,  tampon  methodically  and  firmly  with  sterile  gauze. 

If  the  liver  is  ruptured  extensively  and  tamponade  has  no  effect,  try 
deep  suturing.  If  this  does  not  succeed,  the  wound  is  probably  be- 
yond surgical  aid. 

If  the  spleen  is  extensively  lacerated,  remove  it.     (See  page  482.) 

(d)  If  the  vessels  of  the  posterior  abdominal  wall  are  involved  or 
the  splenic,  mesenteric,  or  renal,  it  will  often  be  very  difficult  to  find 
the  starting-point  of  the  hemorrhage,  for  it  is  in  the  midst  of  a  great 
clot.  Begin  by  applying  a  large  compress  to  the  suspected  point  and 
make  firm  pressure.  Following  this,  rapidly  wipe  out  all  the  clots 
and  reapply  the  compress.  Raise  its  edge  gradually  and  as  each 
bleeding  point  appears,  clamp  it.  It  will  often  be  impossible  to  ligate 
at  that  depth  and  forceps  are  left  attached.  The  forceps  are  to  remain 
twenty-four  to  thirty-six  hours.  These  must  be  removed  without 
violence. 

(3)  Wounds  of  the  intestine:  Do  not  forget  that  intestinal  perfora- 
tions are  often  multiple,  are  usually  so  after  gunshot  wounds,  so  that 
it  is  absolutely  necessary  to  inspect  the  whole  intestine  that  no  wound 
may  be  overlooked. 

(A)  Examination  of  the  Bowel. — The  procedure  must  be  methodical. 
Do  not  pick  up  first  one  segment  and  then  another  indiscriminately; 
in  this  way  one  part  may  be  examined  several  times  and  another  part 
not  at  all. 

Begin  by  picking  up  with  forceps  any  part  of  the  bowel  that  may 
present;  these  forceps  will  serve  as  a  starting-point  and  landmark. 
It  will  not  hurt  the  bowel  with  its  pressure,  as  it  includes  in  its  hold  only 
the  serous  and  muscular  coats  (Fig.  341). 

Begin  at  this  point,  then,  pulling  up  to  view  segment  after  segment, 


474 


LAPAROTOMY   FOR   TRAUMATISM. 


and  as  it  is  inspected,  returning  it  to  the  cavity.  The  manucevre  ma 
be  attended  with  difficulty  especially  if  one  is  compelled  to  operat 
late,  when  peritonitis  has  begun  and  the  partially  paralyzed  bowe 
is  greatly  distended.  If  several  folds  of  the  bowel  should  escape  an] 
there  is  difficulty  in  returning  them,  the  procedure  as  described  01 
page  116  will  be  helpful. 


Fig.  341. — Examining  the  bowel.      (Veau.) 

Begin  by  lifting  up  the  abdominal  wall  by  means  of  the  retractors. 
Cover  the  refractory  mass  with  a  wide  compress  and  then  tuck  each 
border  of  the  compress  into  the  wound,  gradually  working  it  into  the 
abdominal  cavity.  It  will  carry  the  bowel  along.  Then  carefully 
withdraw  the  compress. 

Examining  thus  the  small  intestine,  one  of  its  fixed  points  will 
finally  be  reached,  either  the  cecum  or  the  duodenum;  return  then 
to  the  forceps  and  work  in  the  other  direction.* 

rliffir-ni?6  ^f  °*  Sunthot.  ^ounds  penetrating  the  abdomen  from  behind,   the 

SotSngcaS1118  the  mJUneS  "^  bC  S-^ly  increased,  a  fact  illustrated^ 

On  December  21    1907,  a  colored  man  was  brought  to  the  City  Hospital  with  a 

fnc£:rUnim  tfe£U£  the5Ullet  enterinS  the  "ght  lumbar ^egronabo't Two 
inches  from  the  middle  line.  Progressive  abdominal  distention  and  tendernTss 
with  symptoms  of  hemorrhage  pointed  to  a  visceral  injury.  He  was  immldiSe  y 
operated;  he  abdomen  was  opened  below  the  umbilicus7  The  pelvis  SSaUed 
considerable  blood,  but  there  was  not  the  quantity  expected.  A  Sematk  exam 
mation  of  the  intestine  from  the  cecum  to  the  d/odeno-jejunal  j/nc  ure  reveakd 


i'i  PAIH   01    i\  n  sri\.\i.    win  \\>  I, 


475 


Whenever  a  perforation  is  found,  it  must  be  repaired  before  looking 
further. 

(H)   Repair   of  the    Intestinal    Wound.      When    an    intestinal    won  no1 

is  located,  seize  its  edges  with  two  forceps,  including  only  the  serous 
and  muscular  coats,  draw  the  part  outside  the  cavity  and  isolate  it 
with  compresses  and  then  suture. 

(a)  Non-perforating  wounds  are  sufficiently  repaired  by  two  or  three 
Lembert  sutures. 

(I))  Small  perforating  wounds,  such   as  bullet   wounds,   must    be  re- 


Fig.   342. — The  inclusive  suture  passed;  tied  and  Lembert  suture 
passeil ;  Lembert  tied. 


paired  by  suture  in  two  layers  (Fig.  342).  With  fine  silk,  No.  1, 
make  a  suture  which  includes  all  three  coats,  serous,  muscular  and 
mucous  (Fig.  343).  If  the  wound  is  longer  than  two-thirds  of  an 
inch,  use  two  such  sutures,  etc.  These  sutures  are  to  be  covered  in 
and  buried  by  the  second  layer,  which  involves  only  the  serous  coat 

no  perforation.  No  opening  in  the  posterior  abdominal  wall  could  be  found  be- 
low the  level  of  the  umbilicus.  The  incision  was  extended  and  the  examining 
finger  located  a  tear  behind  the  stomach.  At  this  time  the  patient's  condition 
grew  so  bad  it  was  necessary  to  cease  the  search  and  before  the  abdomen  could  be 
Completely  closed,   he  died. 

The  postmortem    revealed  a  long  tear  in  the  transverse  portion  of  the  duodenum. 
Tlie  bullet  had  struck  the  transverse  process  of  a  lumbar  vertebra,  had  deflected 

to  the  left,  wounding  the  ascending  vena  cava  and  the  duodenum,  and  had  lodged 

in  the  anterior  abdominal  wall.      The  Mood  escaping  from  the  vena  cava  had  not 

emptied  into  the  abdomen,  but  had  followed  the  vein  along  the  spine  and  had  flooded 
the  posterior  mediastinum. 


476 


LAPAROTOMY   FOR   TRAUMATISM. 


(Lembert  suture).  In  introducing  them,  begin  at  least  one-half  inch 
back  of  the  first  line  and  use  either  a  continuous  or  interrupted  suture 
(Fig-  344). 


Fig.  343. — The  first  layer 
of  sutures  include  all  coats. 
(Veau.) 


Fig.  344. — Applying  sero- 
serous  (Lembert)  sutures. 
(Veau.) 


(c)  Large  Perforating  Wounds. — If  the  wound  is  an  incised  one, 
suture  without  refreshing  the  edges,  but  if  it  is  contused  or  lacerated 
(Fig.  345)  it  will  be  necessary  for  repair  to  trim  away  to  the  sound 
tissue;  but  take  care  not  to  diminish  the  caliber  of  the  gut. 


Fig.     345. — Trimming     away 
the  bruised  tissue.      (Veau.) 


Fig.  346. — Transverse  su- 
ture to  prevent  narrowing  of 
the  bowel.      (Veau.) 


As  before,  beginning  at  one  angle,  introduce  the  first  line  of  the 
suture,  including  all  the  coats,  and  using,  if  possible,  a  continuous 
suture  (Fig.  346). 


AFTEE    l'Ki\l\n\i    hi     LAPAROTOMY    POB    TRAUMATISM.  177 

The  second  line  of  (Lembert  or  sero  serous)  sutures  must  begin  and 
ml  one  half  inch  beyond  the  limits  of  the  first  and  the  needle  must  be 
btered  far  enough  away  from  the  first  line  that  the  peritoneal  3uri 

nay  be  well  apposed  and  the  first  layer  completely  covered  (Fig.  347). 

((')  Resection  of  the  Gut.  If  the  wound  involves  more  than  two- 
birds  of  the  circumference  or  if  then-  is  a  contusion  of  the  whole  or 
i  large  part  of  the  segment,  it  will  be  necessary  to  resect  and  do  a 
;ircular  enterorrhaphy  or  some  other  form  of  anastomosis.  If  the 
ipenitor  cannot  undertake  that,  then  the  gut 
must  he  treated  as  in  the  gangrene  of  strangu- 
.aied  hernia,  making  an  artificial  anus  (see 
page  519).     For  resection  of  gut,  see  page  575. 

Drain  the  peritoneal  cavity  with  a  Micu- 
licz  drain  where  there  is  oozing,  and  with  a 
drainage-tube  if  infection  is  feared  (see 
Chapter  V  on  Drainage). 

Close  the  abdominal  wall  by  three  tiers  of  "  "~aj? 

suture;    the  peritoneum  with    a    continuous  Fig.  347.— Applying  Lembert 
suture  of  catgut,  the  muscles  with  chromicized 
catgut,  and  the  skin  with  silkworm-gut.     Apply  a  dry  dressing. 

Subsequent  Care. — Order  complete  rest  and  absence  of  food  for  forty- 
eight  hours,  not  even  excepting  milk.  To  quench  the  thirst,  let  the 
patient  suck  a  cloth  saturated  with  water.  Inject  salt  solution  if 
there  are  signs  of  collapse.  It  will  nearly  always  be  expedient  to  give 
salt  solution  either  by  rectum  or  subcutaneously;  in  the  worst  cases 
by  intravenous  infusion. 

Change  the  dressing  the  following  day.  It  will  probably  be  satu- 
rated with  bloody  serum.  On  the  second  day  remove  the  tampons 
and  replace  with  smaller  ones.  On  the  fourth  day  remove  the  drain- 
age-tube, if  employed,  and  replace  with  smaller  one,  which  may  be 
dispensed  with  after  the  eighth  day. 

Prognosis. — The  prognosis  will  depend  upon  the  extent  of  the 
injuries  and  the  skill  of  the  operator. 

Death  may  occur  from  hemorrhage  or  peritonitis  shortly  after  the 
operation,  or  about  the  eighth  or  tenth  day  if  the  suturing  has  been 
imperfectly  done. 


478  LAPAROTOMY   FOR   TRAUMATISM. 

Fecal  abscess  and  fecal  fistula  may  result,  requiring  a  later  operation, 
or  which  may  eventually  cure  themselves. 

Complete  recovery  happily  very  often  occurs  and  would  be  the  rule 
if  the  doctor  had  the  judgment  or  authority  to  operate  within  the 
first  few  hours  after  the  traumatism. 

WOUNDS  OF  THE  STOMACH. 

If  the  injury  involved  the  upper  pole  of  the  abdomen,  the  stomach 
must  be  examined  carefully.  Extensive  injuries  are  often  overlooked. 
An  escape  of  gas  and  bleeding  may  point  to  the  situation  of  the  lesion. 

Pick  up  the  stomach  with  gauze  to  get  a  firmer  hold,  and  examine 
the  anterior  surface  systematically.  Repair  any  wounds,  as  in  the 
intestine  by  two  rows  of  suture;  the  one  including  all  the  coats,  the 
other  only  the  serous  and  muscular. 

In  the  case  of  gunshot  wounds,  examine  the  posterior  surface.  To 
reach  the  posterior  surface,  Auvray  insists  upon  a  large  incision  in  the 
gastro-colic  omentum  along  the  lower  border  of  the  stomach,  for  a  large 
incision  facilitates  examination  and  does  not  compromise  the  vitality 
of  any  structure .  If  even  then  one  cannot  gain  full  access,  he  advises 
an  exploratory  gastrotomy  (Revue  de  Chirurgie,  Nov.  10,  1906). 

The  posterior  surface  may  be  reached  another  way,  by  turning 
up  the  transverse  colon  and  opening  the  transverse  meso-colon.  To 
prevent  the  spread  of  fluids  which  may  escape  from  the  stomach, 
the  field  must  be  carefully  walled  off  with  compresses  as  the  explora- 
tion proceeds.  If  the  wound  can  be  felt  but  is  impossible  to  be  seen, 
then  no  attempt  must  be  made  to  suture,  but  the  cavity  is  to  be  thor- 
oughly drained. 

If  there  has  been  much  loss  of  substance,  it  may  be  necessary  to  do 
a  gastro-enterostomy. 

WOUNDS  OF  THE  LIVER. 

If  the  nature  of  the  abdominal  injury  leaves  no  doubt  that  the 
liver  is  wounded,  it  may  be  advisable  to  vary  the  procedure  described 
from  the  first.  A  support  under  the  back  tilts  the  abdomen  so  that 
the  intestine  drops  down  toward  the  pelvic  cavity,  and  at  the  same  time 
the  liver  is  bulged  forward  and  made  more  accessible. 


I  ki  \  I  \li  \  I    01    WOUNDS  01     mi     LIVER. 

The  incision  beginning  al  the  ensiform  cartilage  may  follow  the 
festal  arch,  dividing,  if  accessary,  the  right  rectus  muscle.  It  may 
even  be  necessary,  in  order  to  reach  the  upper  surface  of  tin-  liver, 
to  resect  the  u-nth,  ninth,  or  eighth  ribs. 

You  may  find  on  examination  of  the  viscera  that  the  liver  lias  been 
mmtused,  and  there  Is  evidently  a  hematoma  formed  beneath  the  cap- 
Kile.  It  is  bettor  not  (<>  disturb  it  unless  the  conditions  seem  to  indicate 
continuation  of  oozing. 

There  may  be  an  open  wound  of  any  character  or  extent  with  great 
hemorrhage.  One  should  attempt  to  catch  up  and  ligate  the  bleeding 
points,  employing  a  tine  clip  or  artery  forceps.  The  veins,  as  well 
as  the  arteries,  will  stand  the  strain  of  a  ligature,  hut  may  need  to  be 
dissected  loose  from  the  liver  substance  before  the  ligature  can  be 
applied. 

If  the  patient  is  not  too  weak,  attempt  repair  by  suture.  It  is  a 
little  difficult,  but  quite  possible  and  certainly  desirable. 

Employ  a  blunt-pointed  needle  and  do  not  push  it  through  boldly, 
but  slowly,  and  as  you  push,  gently  oscillate  the  needle.  In  this 
manner,  the  point  may  slip  by  the  vessels.  Employ  a  large  catgut 
suture,  as  a  tine  suture  cuts  through  the  soft  tissue  (Fig.  348). 

Van  Buren  Knott  (Iowa  Med.  Journal,  Oct.,  1907)  recommends 
inserting  a  strand  of  catgut  parallel  with  the  liver  wound,  tying  the 
ends  of  the  strand  over  small  skeins  of  catgut  to  prevent  tearing. 
Transverse  interrupted  sutures  are  then  passed  so  as  to  include  the 
parallel    sutures   first  passed. 

Failing  to  suture,  there  is  nothing  left  but  the  tamponade,  and  this, 
of  course,  is  the  only  thing  available  in  lacerated  wounds. 

Wathen,  of  Louisville,  even  advises  (Int.  Jour.  Surgery,  July, 
1906)  that  the  average  operator  use  the  tampon  from  the  first  to  save 
time  and  trouble.  The  gauze  must  be  packed  into  the  wound  with 
firmness  to  prevent  further  hemorrhage,  and  its  end  brought  to  the 
external   wound  that  it  may  be  subsequently  removed. 

Haynes,  of  New  York  (Annals  of  Surgery,  July,  1907),  describes 
a  case  illustrative  of  some  of  the  difficulties  of  treatment  and  the 
sequela:  of  liver  wounds. 

Patient,  a  man  of  twenty  years,  was  brought  to  the  Harlem  Hospital 


480  LAPAROTOMY   FOR   TRAUMATISM. 

with  gunshot  wound  just  below  the  tip  of  the  ensiform  cartilage. 
The  bullet  was  found  to  have  traversed  the  liver  from  before  back- 
ward, and  it  was  necessary  to  get  at  the  wound  of  exit. 

From  the  median  incision,  a  second  incision  was  made  transversely, 
dividing  the  right  rectus  and  the  seventh  and  sixth  costal  cartilages. 
The  falciform  ligament  was  also  divided.     With  strong  traction  upon 


i^iji^w.^!..,^...    ..  ..' -.._' ' 

Fig.  348. — Suture  of  the  liver.      (Moynihan.) 


the  costal  arch,  the  posterior  wound  could  be  reached  and  felt  but  not 
seen,  readily  admitting  two  fingers. 

By  the  sense  of  touch,  an  iodoform  wick  was  packed  into  this  wound 
and  a  smaller  one  introduced  into  the  anterior  wound,  and  both 
brought  out  through  the  abdominal  incision.     This  did  not  entirely 


SI   ii  K'i     01    w>i  NDS   "I     Mil     r\\<  I'l  IS.  \Bl 

control  the  hemorrhage,  and  so  the  liver  was  forced  u j >  against  the 
diaphragm  and  held  by  a  large  M  ii  ulicz  tampon  below  the  liver. 

The  rectus  was  sutured.  The  peritoneum  was  repaired  with  the 
Falciform  ligamenl  included;  the  abdominal  walls  sutured  above  and 
below  the  gauze  wicks. 

On  the  tenth  day  the  tamponade  was  removed;  and  a  few  days 
later   were   removed    the   gauze    wicks,    for   which    rubber  tubes   were 

substituted,  a  discharge  of  bile  and  pus  being  present. 

At  the  end  of  the  third  week  it  became  necessary  to  secure  addi- 
tional drainage,  and  the  ninth  rib  was  resected  in  the  axillary  line, 
where,  in  the  meantime,  the  bullet  had  been  located;  the  costal  and 
phrenic  pleura  were  sutured,  and  the  pleural  cavity  thus  shut  off. 
The  diaphragm  was  opened,  the  pus  drained  out  and  a  long  tube 
passed  from  the  anterior  to  the  posterior  abdominal  wounds,  and  a 
smaller  one  left  in  the  posterior  wound. 

The  progress  of  repair  was  slow  but  sure,  five  months  elapsing 
before  the  cure  was  complete. 

It  should  be  remarked  that  very  rarely  after  gunshot  wounds  of  the 
liver  is  there  notable  external  hemorrhage.  One  must  determine 
the  degree  of  injury  from  the  signs  of  internal  hemorrhage  and  the 
evidences  of  peritoneal  reaction  which  later  develop. 

WOUNDS  OF  THE  PANCREAS. 

Do  not  forget  to  examine  the  pancreas  in  wounds  of  the  upper 
zone  of  the  abdomen.  Reach  the  pancreas  from  above  the  stomach, 
opening  through  the  gastrodiepatic  omentum. 

Carefully  mop  out  the  fluids,  blood  and  pancreatic  juice.  Pack 
around  the  site  with  compresses  and  try  to  suture.  Sometimes  two 
or  three  deep  sutures  will  coapt  the  wound  surface  and  completely 
check  the  hemorrhage.  If  the  tail  is  much  crushed,  resect  it  and 
suture  the  stump.  Use  gauze  and  tubal  drainage.  If  the  patient 
does  not  die,  he  may  have  a  subphrenic  abscess  (Figs.  349,  350). 

WOIXDS  OF  THE  SPLEEN. 

Any  but  the  slightest  wound  of  the  spleen  is  universally  and  rapidly 
fatal  from  hemorrhage  unless  treated.     One  naturally  thinks  of  sutur- 


LAPAROTOMY    FOR   TRAUMATISM. 


ing.  If  that  and  tamponade  are  not  effective  to  stop  the  bleeding,  it 
is  indicated  to  try  to  remove  the  viscus.  This  is  not  difficult  if  there 
are  no  adhesions,  though,  if  there  are,  failure  is  almost  certain. 
Under  such  circumstances,  as  Moynihan  suggests,  the  only  thing  left 
is  to  pack  with  gauze,  soaked,  if  necessary,  in  adrenalin  solution. 

Noetzel  (Beitrage  z.  klin.  Chirurg.)  reviews  his  experience  with 
six  cases  in  which  he  removed  the  spleen  for  injury  and  concludes 
that  splenectomy  is  the  only  safe  way  of  securing  hemostasis.  Suturing 
and  tamponing  may  arrest  bleeding  for  a  time,  but  there  is  danger 
that  it  will  return. 


Fig.  349-  Fig.  350. 

Figs.  349  and  350. — Method  of  suture  of  a  wound  in  the  pancreas.  Two  or  three  deep 
sutures  of  stout  catgut  or  silk  are  passed,  and  the  wound-surfaces  drawn  together.  The 
wound-edges  are  then  sutured  with  fine  catgut  sutures.      (Moynihan.) 

Holliday,  of  Portsmouth,  Virginia,  reports  a  case  illustrating  the 
subject  (Virginia  Medical  Semi-monthly  Journal,  January  11,  1907); 
patient,  boy,  age  15,  was  struck  in  left  side  by  a  flying  pulley,  fracturing 
his  arm  in  several  places  and  contusing  the  abdominal  wall.  His 
condition  shortly  became  serious;  temperature  subnormal,  absolute 
dullness  on  the  left  side,  and  marked  rigidity.  Immediate  operation. 
The  patient  was  almost  eviscerated  before  the  bleeding  could  be 
located,  but  which  was  finally  found  to  proceed  from  the  lacerated 
external  surface  of  the  spleen;  a  splenectomy  was  quickly  done,  and 
the  abdomen  closed  without  drainage.  Convalescence  was  easy 
and  uneventful. 

Splenectomy. — The  operation  following  rupture  generally  finds 
the  incision  made  in  the  middle  line  on  account  of  the  indications  for 
hemorrhage. 


EXTRA-PI  RITON]  \l     WOT  M'S   OF   THE    KIDNEY.  483 

The  spleen  is  broughl  up  into  view  and  delivered  from  the  abdom- 
inal cavity,  avoiding  any  strain  upon  its  pedicle,  for  the  veins  have 
extremely  thin   walls. 

Ligate  and  divide  the  pedicle.  Transfix  the  pedicle  with  ;i  -double 
ligature  and  tie  each  half  separately,  and  finally  tie  the  whole  pedicle 
in  a  single  ligature.  The  pedicle  is  next  divided,  the  spleen  removed, 
and  its  bed  examined  for  any  bleeding  points.  The  under  surface 
of  the  diaphragm  is  very  likely  to  present  some  oozing. 

Fiske,  of  Brooklyn,  describes  a  case  which  illustrates  the  variations 
in  the  procedure.     (Annals  of  Surgery,  Jan.,  1908.) 

A  man  of  twenty-five  years  was  brought  to  the  Kings  County 
Hospital  with  a  bullet  wound  in  the  left  side  corresponding  to  the 
spleen.  The  symptoms  pointed  to  visceral  injury  and  intra-abdominal 
hemorrhage.  An  incision  was  made  over  the  outer  border  of  the  left 
rectus  muscle  from  the  costal  arch  to  a  point  midway  between  the 
umbilicus  and  symphysis.  The  stomach  and  intestine  were  found  to 
be  uninjured.  A  perforation  in  the  transverse  meso-colon  was  re- 
paired, but  the  hemorrhage  continued.  A  transverse  incision  was 
made  and  the  spleen  examined,  revealing  a  rent  which  admitted  two 
fingers.  The  spleen  was  pulled  up  into  the  wound,  the  pedicle  clamped 
and  ligated  en  masse.  After  removing  the  spleen,  the  vessels  were 
ligated  separately,  the  abdomen  was  flushed  with  saline  solution, 
a  small  gauze  drain  left  in  contact  with  the  stump,  and  the  wound 
closed  with  through-and-through  silkworm-gut  sutures.  The  tem- 
perature subsequently  did  not  rise  above  ioo°.  The  drain  was 
permanently  removed  on  the  fifth  day.  The  patient  left  the  hospital 
at  the  end  of  the  third  week,  entirely  recovered. 

WOUNDS  OF  THE  KIDNEY. 

If,  while  examining  the  viscera  in  the  course  of  the  laparotomy, 
you  find  a  ruptured  renal  pelvis  or  a  seriously  lacerated  kidney  bleed- 
ing into  the  peritoneal  cavity,  remove  the  kidney.  Make  a  longitu- 
dinal incision  in  its  peritoneal  covering,  strip  the  organ  out  of  its  bed 
and,  lifting  toward  the  surface,  free  the  pedicle. 

Ligate   the   ureter   first   and   then,   if   possible,   each   of  the  vessels 


484  LAPAROTOMY   FOR   TRAUMATISM. 

separately.  If  the  oozing  persists,  leave  a  Miculicz  drain  or  a  rubber 
tube. 

Intra-peritoneal  rupture  without  injury  to  other  viscera  is  very  rare. 

Extra-peritoneal  wounds  of  the  kidney  do  not,  as  a  rule,  require 
intervention. 

That  the  kidney  has  been  involved  will  be  suggested  by  pain, 
frequent  micturition,  and  bloody  urine. 

Rest  in  bed,  morphia,  and  limited  diet  are  the  special  indications. 
An  abdominal  binder  may  give  relief. 

Eliot  (American  Journal  Surgery,  Nov.,  1906)  has  observed  twelve 
cases  of  subcutaneous  rupture  of  the  kidney.  In  seven  cases  there 
was  not  sufficient  extravasation  to  make  a  perceptible  tumor,  and  the 
diagnosis  was  made  by  the  hematuria  and  the  tenderness  over  the 
kidney  and  persistent  rigidity  for  a  number  of  days. 

In  the  remaining  cases  a  well-defined  tumor  appeared  in  the  ilio- 
costal space,  becoming  more  sharply  outlined  as  the  rigidity  dis- 
appeared. In  five  or  six  weeks,  the  tumor  disappeared.  In  no 
instance  was  operation  necessary. 

In  such  cases  of  extra-peritoneal  rupture  as  require  operation,  the 
lumbar  route  should  be  chosen.  Operation  is  indicated  from  the  first 
if  the  violence  was  known  to  be  great  and  a  large  tumor  forms  im- 
mediately. An  operation  is  indicated  at  any  time  symptoms  of  sepsis 
appear. 

Morris  Miller  reports  a  case  (Annals  of  Surgery,  Feb.,  1908)  of  a 
man  who  fell,  striking  his  left  side  over  the  lower  rib.  He  felt  faint, 
and  almost  immediately  passed  a  quart  of  blood  by  the  urethra  and 
later  many  clots.  Miller  saw  him  at  the  hospital  an  hour  and  a  half 
later.  There  was  no  shock,  but  the  side  was  rigid  and  tender,  and  an 
indistinct  dull  mass  could  be  felt  in  the  loin.  An  oblique  lumbar 
incision  revealed  an  extensive  rupture  of  the  kidney  with  much  hemor- 
rhage. Wicks  of  gauze  were  placed  in  front  and  behind  the  kidney 
and  the  ruptured  segments  pressed  together.  The  patient  did  well, 
the  hemorrhage  gradually  ceased,  though  twice  after  the  fifth  day 
blood  appeared  in  the  urine.  On  the  twelfth  day  the  packing  was  all 
removed,  and  the  opening  finally  healed.  Gibbon,  commenting  on 
the  case,  remarks  that  hemorrhage  severe  enough  to  require  operation 


REPAIR    OP    WOUNDS    01     CHI     BLADDER. 


485 


noes  not  usually  mean  injur}  sufficient  to  require  nephrectomy.  The 
question  of  nephrectomy  must  be  decided  when  the  kidnej  is  exposed. 
Stewart  adds  that  the  two  early  indications  for  operation  arc  a 
progressively  increasing  hematoma  and  constitutional  symptoms  Of 
hemorrhage.  In  several  cases  of  moderate  bleeding  he  had  operated, 
and  afterward  been  sorry  he  had  interfered. 


WOUNDS  OF  THE  BLADDER. 

Wounds  of  the  Madder,  if  not  previously  suspected  from  the  nature 

of  the  abdominal  injuries,  are  inferred   from  the  presence  of  urine  in 


Fir,.  351. — Repair  of  ruptured  bladder.  Applying  through  and  through  sutures.  Subse- 
quently Lembert  sutures  will  he  applied  ami  anally  the  parietal  peritoneum  will  he  repaired 
beginning  at  point  of  reflection  onto  the  bladder.     Peritoneum  retained  by  forceps.  ■  I 

the  peritoneal  cavity.  Sometimes  the  rent  is  hard  to  locate.  Inject 
the  Madder  with  normal  sail  solution  and  observe  its  mode  of  entrance 
into  the  peritoneal  cavity. 


486- 


LAPAROTOMY    FOR   TRAUMATISM. 


The  wound  is  to  be  repaired  by  two  rows  of  sutures,  the  first,  of 
catgut,  involving  all  the  coats  except  the  mucosa;  the  second,  of  silk, 
includes  the  peritoneum  alone  after  the  manner  of  the  Lembert  suture. 
The  stitches  of  both  rows  must  be  closely  placed  to  seal  the  wound. 
The  result  may  be  tested  by  filling  the  bladder  with  normal  salt  solu- 
tion, and  any  defect  repaired  (Fig.  351). 

A  catheter  should  be  left  in  the  bladder  for  drainage  and  the  siphon- 


Fig.  352. — Van 
Hook's  ureteral  an- 
astomosis (Binnie.) 


Fig.  353. — Van  Hook's 
ureteral  anastomosis. 
(Binnie.) 


Fig.  354. — Anasto- 
mosis completed. 
(Binnie.) 


age  kept  up  for  two  or  three  days.  Subsequently,  the  bladder  should 
be  emptied  by  aseptic  catheterization  for  a  few  days  longer.  The 
peritoneum  should  be  drained  for  the  first  forty-eight  hours. 

This  mode  of  treatment  applies  to  the  intraperitoneal  wounds  of 
the  bladder.  The  extraperitoneal  wounds  should  be  treated  on  the 
same  principle,  but  often,  under  such  circumstances,  the  operator 
must  be  content  with  suprapubic  drainage  of  the  bladder  until  the 
wound  has  healed. 


\\  VSTOMOSIS   "I     mi     i  RETER.  ls7 

WOUNDS  I  »l    THE  URETER. 

If  ii  is  discovered  thai  the  ureter  is  wounded  either  by  the  trauma 
or  in  the  course  of  the  operation,  an  effort  should  be  made  at  repair. 
Several  methods  are  available.  It"  the  injury  does  not  amount  to 
complete  division,  a  few  perforating  sutures  followed  by  Lembcrt 
sutures  may  succeed.  Small  wounds  usually  heal  readily,  but  it  is 
safer  to  use  drainage. 

If  the  separation  is  complete,  both  ends  of  the  torn  ureter  may  be 
ligated,  or  the  kidney  may  be  removed,  but  naturally  it  is  preferable, 
if  possible,  to  establish  an  anastomosis.  Under  various  circumstances, 
the  proximal  end  may  be  anchored  in  the  bladder  or  in  the  bowel, 
or  the  two  ends  may  be  brought  together. 

Van  Hook's  termino-lateral  anastomosis  is  generally  applied. 
The  technic  may  be  briefly  described  in  this  wise: 

Ligate  the  distal  portion  one-quarter  inch  from  the  end  and  make 
a  longitudinal  slit  double  the  diameter  of  the  tube  in  length.  Split 
the  proximal  end  also  for  one-quarter  inch,  beginning  at  the  free  end. 

Pass  the  sutures.  Employ  a  long  catgut  suture  threaded  on  a 
needle  at  each  end.  One-eighth  inch  from  the  end  of  the  proximal 
portion  of  the  ureter,  pass  the  two  needles  from  without  inward 
(Fig.  352).  Carry  the  two  needles  through  the  split  in  the  distal 
portion,  into  the  lumen  and  let  them  emerge  one-half  inch  below 
the  end  of  the  split  (Fig.  353).  Tighten  the  suture,  which  will  have 
the  effect  of  invaginating  the  upper  segment  in  the  lower  (Fig.  354). 
Around  the  line  of  contact  run  a  Lembert  suture,  and  cover  with  omen 
turn  or  peritoneum. 


CHAPTER  VIII. 

APPENDICITIS.    APPENDICEAL  ABSCESS.    PURULENT 
PERITONITIS.* 

Inflammation  of  the  appendix  presupposes  two  factors,  lowered 
resistance  and  a  pathogenic  germ. 

The  lowered  resistance  of  the  appendicial  tissue  may  find  its 
origin  in  many  diverse  conditions  involving  its  morphology,  anatomy, 
and  physiology.  It  is  generally  agreed  that  it  is  an  organ  undergoing 
a  retrograde  metamorphosis,  or,  at  any  rate,  one  adapting  itself  to 
new  functions. 

There  is  a  small  facility  for  compensatory  circulation  if  its  main 
artery  is  blocked,  and,  in  consequence,  it  is  exposed  to  vicissitudes  of 
nutrition. 

Owing  to  its  varying  position,  it  is  brought  into  contact  and  may 
acquire  connections,  vascular  and  lymphatic,  with  other  abdominal 
and  pelvic  organs  and  structures  and,  by  this  means,  be  the  recipient 
of  pathogenic  bacteria  that  had  not  elsewhere  found  a  favorable  soil. 

The  pathogenic  organisms  which,  under  favorable  conditions,  may 
here  develop  and  produce  various  grades  of  destruction  are  the  bacillus 
communis  coli,  the  streptococci,  staphylococci,  and  others  less  frequent. 

Whatever  part  of  each  of  these  causative  agents  may  play  in  its  devel- 
opment, the  fact  remains  that  appendicitis  is  one  of  the  frequent  and  one 
of  the  most  dangerous  and  treacherous  diseases  with  which  the  general 
practitioner  has  to  deal. 

Diagnosis. — The  diagnosis  is  not  difficult  in  the  typical  cases, 
but  exceptionally  may  be  extremely  difficult,  or  even  impossible, 
until  the  progress  of  the  symptoms  has  been  observed. 

A  diagnosis  should  never  be  made  from  the  mere  presence  of  what 

*So  important  is  this  subject  to  the  general  practitioner,  that  he  should  be  satis- 
fied to  have  and  study  no  works  Lss  complete  than  the  classic  volumes  of  Deaver 
or  Kelly. 


DIAGNOSIS   "i     M'l'i  \i'l<  Ml-. 


489 


L  regarded  as  the  cardinal  symptoms;  Dot  until  each  symptom  and 
,j„n  has  been  weighed  and  accorded  its  proper  significance,  and  all 
Eer  possible  conditions  excluded,  should  it  be  decided  definitely 
hat  the  case  is  or  is  not  acute  appendicitis. 

To  discuss  briefly  the  symptoms  upon  which  one  must  rely:  the 
kin  in  the  milder  catarrhal  cases  is  limited  usually  to  the  right  iliac 
fossa.  In  the  ulcerative  type,  with  sudden  onset,  or  the  perforate 
type,  it  is  very  likely  at  first  to  he  general  over  the  abdomen,  hut  after 
a  lew  hours,  'is  rather  definitely  localized  in  the  right  side.  In  the 
gangrenous  cases,  it  may  be  absent  in  one  case  or  severe  in  another, 
depending  upon  the  degree  of  active  peritoneal  inflammation. 

Rigidity  of  the  right  rectus  abdominis  and  pelvic  muscles  is  an 
important  sign,  and  its  degree  is  some  index  to  the  amount  of  peri- 
toneal involvement. 

Gastric  disturbance,  nausea,  and  vomiting  are  fairly  constant  occur- 
rences in  the  first  stages  of  the  attack,  but  last  only  a  short  time. 
T.  B.  Eastman  (Ind.  Med.  Jour.,  Jan.,  1907)  has  very  strongly 
emphasized  the  frequent  connection  between  the  chronic  forms  of 
appendicitis  and  those  appearances  of  gastric  indigestion  vaguely 
grouped  as  "stomach  troubles." 

I  Constipation  is  almost  the  rule,  and  Kelly  adds  further  that  it  may 
amount  to  an  actual  obstruction.  Only  rarely  does  diarrhea  appear 
with  the  attack,  and  if  it  does,  may  be  regarded  as  indicating  a  grave 
form.  Most  rare  of  all  is  it  for  an  attack  even  of  the  mildest  type, 
to  run  its  course  without  some  aberration  of  bowel  action. 

Tenderness  on  pressure  is  a  symptom  upon  which  alone  the  diagnosis 
is  too  often  made.  It  is  scarcely  possible  for  it  to  be  wholly  absent, 
and  yet  it  can  by  no  means  be  relied  upon  to  indicate  the  severity 
of  the  attack.  Rosving  (Central.  Blatt.  f.  Chirurgie,  October  26, 
1907)  states  that  pressure  on  the  left  McBurney  point  always  elicits 
pain   in    appendicitis,  but  not  in  other  cases. 

Robert  Morris  (Am.  Jour.  Surg.,  Jan.  25,  1908)  adds  something 
to  this  phase  of  the  diagnosis.  He  claims  that  tenderness  upon  pressure 
over  a  point  opposite  the  umbilicus  in  the  line  of  the  anterior  superior 
spine  of  the  ilium  has  a  special  significance  and  is  due  to  involvement 
Of  the  lumbar  ganglia.     Thus  Morris'  point  on  the  right  side  will  be 


49°  APPENDICITIS.      PURULENT   PERITONITIS. 

tender  in  appendicitis.     If  that  point  on  both  sides  is  tender,  the 
trouble  is  located  in  the  pelvis. 

Tumor. — It  is  folly  to  wait  for  this  sign  to  complete  the  diagnosis, 
for  it  means  the  certainty  of  a  complicated  pathology.  It  means 
peritoneal  involvement  with  plastic  exudates,  or  a  pus  formation,  or 
both. 

Disturbance  of  Pulse  and  Temperature. — There  is  no  other  grave 
disease,  perhaps,  in  which  the  pulse  and  temperature  make  such 
limited  excursions.  The  temperature  in  the  most  serious  cases  may 
not  reach  1030.  Its  elevation  is  in  no  wise  significant.  The  pulse 
in  the  milder  cases  holds  a  certain  ratio  with  the  temperature.  A 
temperature  of  1010,  for  example,  should  be  accompanied  by  a  pulse 
rate  of  90  to  100.  Any  marked  disturbance  of  this  ratio  is  extremely 
significant;  whether  it  is  a  low  temperature  with  a  rapid  pulse  or  a 
high  temperature  with  a  slow  pulse,  the  outlook  is  ominous.  H.  O. 
Panzter,  from  extended  clinical  experience,  insists  that  we  must  rely 
largely  upon  the  rectal  temperature  in  making  a  differential  diagnosis, 
and  that  the  temperature  should  be  invariably  taken  by  both  mouth 
and  rectum.  The  temperature  by  mouth  in  such  cases  may  be  very 
deceptive. 

Such,  very  briefly,  are  the  principal  symptoms  and  signs  which, 
taken  collectively,  must  serve  to  distinguish  the  disorder  from  accute 
intestinal  obstruction,  ovarian  or  tubal  inflammation,  cholecystitis, 
typhoid  fever,  pneumonia,  and  other  acute  diseases. 

There  is  not  much  danger  at  the  present  time,  so  prominently  is  the 
subject  before  the  profession,  that  an  appendicitis  will  be  overlooked. 
Only  too  often  is  an  innocent  appendix  held  to  be  the  cause  of  the 
illness  in  hand.  Edmund  Clark  (personal  communication)  cites  a 
number  of  instances,  quite  recently,  where  called  to  operate,  he  has 
found  a  lobar  pneumonia  and  nothing  more.  Benneche  (Med. 
Klin.,  Berlin,  Feb.  14,  1909)  emphasizes  the  danger  in  mistaking  a 
lobar  pneumonia  for  appendicitis,  and  states  that  pneumonia  in  the 
right  upper  lobe  is  most  liable  to  give  rise  to  appendicial  symptoms. 
Such  cases  are  likely  to  run  an  atypical  course. 

It  is  an  appendicitis,  but  what  is  its  character?  Is  it  mild  or 
dangerous  ?     Is  it  a  simple  catarrhal  trouble  which  will  soon  subside, 


VARU  in  s   in     \rn  Mm  1 1  is.  49  J 

ar  is  it  potentially  ;i  gangrenous  pro<  ess  w  ith  general  peritonitis  ahead  ? 
these  are  the  questions  which  confound  the  doctor  and  upon  their 
answer  rest  the  prognosis  and  treatment. 

Four  varieties  are  described. 

(i)  Catarrhal  appendicitis,  in  which  the  mucosa  alone  is  involved, 
tlic  predisposing  causes  arc  easily  relieved,  and  the  pathogenic  agent 
is  of  a  low  order  of  virility.  Neither  local  nor  constitutional  symptoms 
are  severe,  and  the  attack  very  shortly  subsides. 

(2)  In  the  ulcerative  type  the  process  extends  deeper  and  involves 
the  muscular  and  perhaps  the  serous  coat  to  some  extent  and  there 
is  produced  a  mild  form  of  peritoneal  inllammation.  There  is  usually 
a  diffused  swelling  of  the  whole  appendix. 

(3)  Perforative  appendicitis,  in  which  there  is  local  destruction  of 
all  the  coats  and  communication  with  the  peritoneal  cavity,  is  due  to 
a  sudden  and  virulent  infection  or  an  acute  exacerbation  of  a  slumber- 
ing process  and  begins  abruptly  with  intense  pain;  and  in  a  short 
time  ends  in  peritoneal  suppuration,  local  or  general. 

(4)  Gangrenous  Appendicitis.- — This  form  beginning  as  such  is  the 
post  treacherous,  for  often  the  symptoms  are  in  no  wise  proportionate 
to  the  seriousness  of  the  case.  Death  is  impending,  and  yet  neither 
the  pain,  pulse,  nor  temperature  gives  due  warning.  There  is  ab- 
solutely no  way  at  this  present  time  by  which  the  doctor  may  recognize 
pis  condition  de  >!<>:•<>.  It  may  be  imagined  that  such  a  condition 
arises  from  sudden  interference  with  the  blood  current  to  the  organ, 
while  infection  plays  the  lesser  part.  On  the  other  hand,  gangrene 
which  ensues  from  virulent  infection  begins  at  once  with  the  char- 
acteristic symptoms  of  appendicitis  added  to  those  of  sepsis  and 
peritonitis. 

It  is  from  the  point  of  view  of  these  pathological  variations  that 
the  most  diverse  opinions  as  to  treatment  have  arisen. 

It  is  evident  that  nature,  unaided,  may  be  able  to  take  care  of  the 
milder  type.  It  is  a  clinical  fact  that  nature  by  means  of  her  own, 
may  sometimes  control  and  keep  the  inllammation  within  bounds, 
even  in  the  more  dangerous  cases.  By  means  of  plastic-  exudates,  she 
walls  off  and  limits  the  suppurating  area  and  later  provides  a  safe 
Beans  of  escape  for  the  produi  tS  of  Suppuration.      But,  unfortunately. 


492  APPENDICITIS.      PURULENT   PERITONITIS. 

such  a  happy  issue  can  never  be  depended  upon.  On  the  contrary, 
the  suppuration  is  more  likely  to  become  diffuse  and  there  presents 
the  picture  of  purulent  peritonitis  and  the  imminent  prospect  of  a 
fatality.     In  such  a  case  one  loses  sight  of  the  local  symptoms. 

The  abdomen  is  rigid,  tympanitic  and  everywhere  exceedingly 
tender.  The  temperature  is  high;  the  pulse  rapid;  the  tongue  coated, 
brown  and  fissured;  and  as  the  disease  progresses,  the  symptoms  of 
circulatory  collapse  appear.  The  temperature  then  becomes  sub- 
normal, the  pulse  almost  uncountable,  and  the  features  pinched  and 
anxious,  until  finally  a  mild  delirium  with  pleasant  hallucinations 
ushers  in  the  end. 

The  infection  may  be  so  severe,  the  toxemia  so  profound,  that  the 
patient  may  die  of  septic  peritonitis  before  pus  has  had  time  to  form. 
Indeed,  death  may  come  from  sepsis  before  the  ordinary  signs  of  in- 
flammation appear. 

Such  may  be  the  outcome  of  what  appears  to  be  the  mildest  case. 
It  is  this  prospect  and  the  attendant  uncertainties  which  have  led 
many  doctors  to  regard  appendicitis  as  an  emergency  to  be  operated 
upon  as  soon  as  the  diagnosis  is  made.  As  Pfaff,  of  Indianapolis,  puts 
it,  the  difference  between  the  mortality  of  i  per  cent,  in  the  very 
early  operations,  and  that  of  15  to  30  per  cent,  in  the  abscess  stage, 
is  so  frightful  that,  in  comparison,  an  occasional  unnecessary  operation 
is  of  no  consequence  at  all.  If  we  are  to  fulfill  our  obligations,  we 
must  act  vigorously  and  to-day. 

This  is  undoubtedly  a  safe  rule  in  the  practice  of  the  skilled  operator, 
who  has  at  his  command  all  the  facilities  of  the  aseptic  operating- 
room  and  trained  assistants. 

The  case  is  quite  different  with  the  general  practitioner,  remote 
from  these  accessories.  Moreover,  it  is  known  that  80  to  85  per  cent, 
of  these  cases  recover  without  operation.  Even  for  the  relapsing 
form,  Treves  says  that  much  may  be  done  by  medical  means,  diet,  at- 
tention to  the  bowels,  and  by  placing  the  patient  under  conditions  more 
favorable  to  a  state  of  peace  within  the  abdomen. 

Whatever  may  be  proper  in  hospital  practice,  it  certainly  cannot 
be  imposed  on  the  general  practitioner  that  he  operate  at  once.  Even 
in  connection  with  the  skilled  surgeon,  it  may  be  said  that  his  technic 


I  Kl    \  I  Ml    \  I      01      M'l'l    \l>l<    II  E.  10.} 

has  not  yet  reached  such  a  degree  of  perfection  that  an  operation 
is  always  safer  than  the  milder  form  <>i"  appendii  Itis  unoperated. 

The  doctor  then  will  face  his  responsibility,  a  heavy  one  truly, 
mowing  there  is  much  t<>  be  accomplished  by  medical  means  and 
vet  hoping  thai  he  will  have  the  judgment  to  recognize  the  failure  of 
his  art  ami  nature,  and  the  will  to  resort  not  too  late  to  more  radical 
measures. 

Assume  that  the  diagnosis  is  definitely  made:  assume  that  no  sur- 
geon is  within  beck  and  call  (for  appendicitis  is  strictly  a  surgical 
disease),  what  will  you  do?  It  is  evident  at  onee  that  this  is  a  clinical 
hypothesis,  and  the  question  is  to  be  resolved  on  a  clinical  basis. 

I.  You  see  the  case  from  the  first.  The  attack  begins  mildly  or 
with  only  moderate  severity;  there  was  perhaps  a  single  attack  of 
vomiting;  the  pain,  abdominal  tenderness  and  rigidity  are  not  marked, 
and  the  patient's  general  condition  is  good. 

Under  these  circumstances,  as  Lejars  says,  it  is  perfectly  legitimate 
to  institute  a  medical  treatment,  in  the  meantime  holding  the  case 
under  the  strictest  surveillance.  But  this  formula  is  null  without  the 
last  provision.  If  the  march  of  the  disease  cannot  be  watched,  it  is  better 
to  operate  at  onee.  and  this  rule  may  as  well  be  made  to  apply  to  any 
case  in  which  delay  might  otherwise  be  counselled.  You  decide  to 
try  medical  treatment,  but  in  what  form?  Like  many  others  herein 
involved,  the  question  brings  forth  a  varied  response. 

Under  these  circumstances  one  may  follow  the  plan  of  "immobili- 
zation." which  Lejars  and  others  so  highly  praise.  But  to  be  effective, 
it  must  be  rigorously  and  consistently  applied. 

Keep  the  patient  absolutely  quiet  in  bed.  Give  no  purgatives — 
ami  this  means  give  neither  calomel  nor  oil.  Give  no  enemas.  Sus- 
pend nourishment  absolutely,  relieving  thirst  by  a  few  drops  of  water 
frequently  given. 

Ice  to  the  Abdomen. — Not  a  handful  of  ice  in  a  little  bag  applied  over 
the  iliac  fossa,  but  two  or  three  large  bags  covering  the  whole  abdomen 
below  the  umbilicus  and  refilled  as  the  ice  melts. 

Opium,  in  i  >-grain  doses  in  pill  form  every  two  hours  for  an  adult; 
but  it  must  not  be  pushed  to  the  point  of  annulling  all  pain  and  sus- 
pending the  functions  of  the  kidney. 


494  APPENDICITIS.      PURULENT   PERITONITIS. 

It  is  far  from  being  the  rule  that  the  practitioner  remote  from  the 
larger  towns  can  have  ice  at  his  command.  Likewise,  opium  in  the 
hands  of  the  inexperienced  may  be  a  two-edged  tool.  He  must  often, 
therefore,  depend  upon  other  modes  of  procedure,  and  for  these, 
there  is  no  lack  of  eminent  authority.  Under  the  circumstances  in- 
dicated, begin  with  a  single  hypodermic  of  morphia  if  the  pain  is 
severe  and  with  small  doses  of  calomel  (1/20-1/ 10  gr.)  frequently 
repeated,  until  a  grain  or  two  is  taken;  follow  at  the  end  of  three  hours 
with  a  large  dose  of  castor  oil  or  larger  doses  of  albolene  until  the 
bowels  have  moved  freely.  Give  an  immediate  soapsuds  enema. 
If  the  bowels  are  slow  to  move,  supplement  the  internal  remedies  with 
enemas  of  normal  salt  solution.  Give  salol  or  carbonate  of  guaiacol 
every  three  hours.  Apply  hot  fomentations  to  the  abdomen,  flannels 
wrung  out  of  hot  water  and  sprinkled  with  turpentine.  Cover  the  hot 
flannels  with  several  additional  thicknesses  and  apply  hot-water 
bottles  filled  with  boiling  water,  and  cover  the  whole  to  retain  the  heat. 
As  the  water  cools,  withdraw,  one  by  one,  the  various  layers  so  that  the 
temperature  may  be  maintained  at  the  highest  point  of  comfort. 
Hot  kaolin  cataplasms  often  render  service. 

As  Oschner  commands,  food  must  be  withheld  absolutely,  and  if 
there  is  much  gastric  disturbance  or  pain,  the  stomach  should  be 
washed  out.     Opium  is  contraindicated  under  this  form  of  treatment,  | 
for  it  is  the  purpose  to  cleanse  the  bowel. 

McGrath,  of  New  York,  probably  expresses  the  prevailing  opinion, 
summing  the  matter  up  in  this  wise  (Medical  Record,  Feb.  1,  1908): 

"Only  in  the  catarrhal  cases  can  there  be  any  question  as  to  treat- 
ment once  the  diagnosis  is  made;  whether  it  is  better  to  operate  without 
delay  or  seek  to  avail  oneself  of  the  advantage  of  an  interval  oper- 
ation. If  sure  of  the  character  of  the  lesion,  we  may  temporize;  it  will 
do  no  harm  watching  the  patient  carefully  for  any  sign  of  danger. 
Many  of  these  cases  resolve  without  going  on  to  suppuration  or  gan- 
grene, and  therefore  escape  operation  during  the  acute  attack.  Nature 
may  be  assisted  in  her  efforts  at  spontaneous  cure  in  these  cases  by  en- 
joining complete  rest,  withholding  all  food  and  permitting  only  water 
to  be  taken,  and  by  small  repeated  doses  of  calomel  and  sodium 
bicarbonate.     An  ice-bag  may  be  applied  over  the  region  of  the  ap- 


TREATMENT   OP   APPENDICITIS.  495 

,)cn<lix.     But  if  there  is  any  doubt  as  to  the  exact  pathological  condi 
.ion,  operation  should  Ik-  advised   unless  marked  contraindications 

:xist." 

George  J.  Cook,  of  Indianapolis,  who  has  had  as  much  experience 
with  this  disease  as  anyone  in  the  Mississippi  Valley,  does  not  operate 
in  mild  attacks  of  primary  appendicitis.  If  it  is  a  second  attack,  he 
operates  without  delay.  He  says  that  not  infrequently  a  mild  catar- 
rhal appendicitis  does  not  recur.  In  such  cases,  he  puts  the  patient  at 
rest.  He  unloads  the  bowels  with  enemas  merely.  If  the  attack 
follows  overeating,  he  employs  a  mild  saline  primarily.  Nothing  but 
water  is  permitted.  As  an  intestinal  antiseptic,  he  gives  five  grains  of 
carbonate  of  guaiacol  three  or  four  times  in  the  twenty-four  hours. 
If  the  patient  should  complain  much,  he  gives  small  doses  of  opium, 
after  the  diagnosis  is  made.  He  gives  it  to  quiet  the  pain  and  not  the 
peristalsis,  asserting  that  the  bowel  will  of  itself  be  quiescent  if  empty. 
Ice-bags  applied  to  the  abdomen  as  a  routine  measure  represents  to 
him  the  chief  element  in  the  relief  of  pain  and  control  of  inflammation. 

Note  that  whatever  the  form  of  treatment,  the  case  must  be  nar- 
rowly watched.  If  the  pulse  and  temperature  remain  in  harmony; 
»if  the  abdominal  tension  and  tenderness  tend  to  grow  less;  if  the 
bowels  move  and  gas  escapes  per  rectum;  if  the  general  condition  is 
good;  there  is  ground  to  expect  a  satisfactory  termination,  but  no 
excuse  to  relax  one's  vigilance. 

No  nourishment  should  be  given  by  mouth  until  defervescence  is 
complete,  and  after  that  a  liquid  diet  should  be  maintained  for  one  to 
two  weeks,  depending  upon  the  severity  of  the  attack,  and  rest  in  bed 
as  well.     At  the  end  of  a  few  weeks,  the  appendix  should  be  removed. 

But  the  progress  of  the  disease  may  suddenly  change.  All  the 
symptoms  may  become  aggravated  and  the  dangerous  nature  of  the 
case  become  at  once  obvious — immediate  operation  is  indicated; 
or  the  change  may  be  insidious  (unsuspected  by  the  careless  observer) 
and  in  this  instance  the  chief  reliance  must  be  placed  upon  the  pulse. 
If  the  pulse  is  rapid  and  weak  with  a  falling  temperature,  or  if  the 
pulse  falls  to  50  or  60  with  a  rising  temperature;  in  other  words,  if  there 
is  any  marked  divergence  between  pulse  and  temperature,  again  the 
indications  are  to  operate  at  once.     To  repeat,  any  marked  aggrava- 


496  APPENDICITIS.      PURULENT   PERITONITIS. 

tion  of  the  symptoms  after  improvement  once  begins,  or  the  occurrenc 
of  any  marked  disparity  between  pulse  and  temperature,  howevi 
benign  the  other  symptoms  may  be,  are  indications  for  operatic 
without  delay. 

II.  Another  case:  You  have  watched  the  case,  but  the  temperature 
has  persisted,  and  beyond,  say  the  sixth  day,  when  there  should  be  i 
marked  improvement,  you  find  the  temperature  rising  or  fluctuating 
the'  pain  increasing,  a  tumor  forming  most  painful  at  its  center.  Ir 
this  case  also  the  indication  is  for  immediate  operation. 

III.  Suppose  you  see  the  case  only  at  the  end  of  several  days,  during 
which  time  the  disease  has  run  a  neglected  course.  May  one  at  thi: 
time,  with  any  effect,  apply  a  medical  treatment,  or  should  one  resori 
at  once  to  an  operation?  The  question  can  only  be  answered  after  i. 
careful  consideration  of  the  history  of  the  case,  such  as  the  patient  oi 
his  attendants  can  give,  and  a  thorough  investigation  of  the  presen 
symptoms.  Only  when  the  case  is  obviously  benign  can  one  take  the 
responsibility  of  further  delay.  For  example,  if  the  pulse  and  tern 
perature  are  in  accord,  if  the  tenderness  and  tympanitis  are  diminish 
ing,  then  nothing  better  can  be  done  than  to  follow  the  rules  wit! 
regard  to  rest  and  diet  already  laid  down.  Yet  one  must  be  eve] 
mindful  of  the  treacherous  character  of  certain  forms  of  septic  attack 

Again,  you  find  the  disease  progressing  and  in  the  active  stage  o 
the  third,  fourth,  or  fifth  day,  with  no  indications  of  beginning  im 
provement,  but  the  symptoms  are  not  aggravated,  and  there  is  a  plastic 
exudate  without  softening:  again  it  may  be  said  that  under  these  cir- 
cumstances it  is  legitimate  to  wait. 

Any  continuance  of  the  fever  beyond  the  eighth  or  tenth  day,  ever 
though  the  pulse  is  good  and  the  exudate  has  not  softened,  is  a  mattei 
of  grave  suspicion,  and  with  the  least  enlargement  of  the  tumor  01 
disturbance  of  pulse,  operate  without  delay,  and  it  is  more  than  likely 
you  will  find  a  large  abscess. 

IV.  In  any  case,  at  any  stage,  if  a  diagnosis  of  abscess  can  be  made 
out — a  palpable  fluctuating  mass,  in  the  iliac  fossa — whatsoever  the 
other  symptoms  may  be,  there  is  but  one  indication  immediate 
operation.  No  practitioner  to  whom  the  task  falls,  whatsoever  his 
ability  or  training,  can  do  anything  else  and  do  his  duty.     Even  though 


dim  R  \  i  [ON    I  OR    M'l-l  NDK  M  [S. 


497 


you  cannol  detect  fluctuation,  but  by  vaginal  and  rectal  examination 
determine  that  the  mass  is  doughy  and  painful,  operate  and  you  will 
almost  certainly  find  pus. 

Y.   Finally,  even  it'  the  rase  has  progressed  to  a  general  peritonitis, 


/  ;mV"\ 

/  M\v\ 

/    J  m  li'-  \ 

"~^^BB  4  J  at' 

V"^'-m\  Mi         ^m  1*        J 

-»«^2 

\&'':.\\m'i    .  •    ■  «A  7 

Y'\l  iJhv 

• 

\v /K^^H  /^ '  V^ 

\    '*wf 

\^<-S 

\/xjc 

Fig.  3SS- — Vertical  incision  through  skin,  aponeurosis  and  sheath  of  rectus. 
Outer  border  of  rectus  exposed  in  bottom  of  wound. 

it  is  one's  duty  to  operate  unless  the  patient  be  practically  moribund, 
and  even  in  these  cases,  as  Lejars  puts  it,  operation  has  rescued  a 
Certain  number  of  patients  from  the  very  jaws  of  death,  for  without 
operation  they  would  inevitably  have  died. 

Even   though   the  diagnosis  is  not  definitely  established  and  one 
32 


498 


APPENDICITIS.      PURULENT   PERITONITIS. 


considers  the  possibility  of  meeting  with  a  tubercular  peritonitis  or  a 
salpingitis  or  similar  condition,  yet  the  rule  should  be  to  operate  in  any 
case  of  doubt. 

Operation. — Two  operations  will  be  described:  A,  when  no  pus  or 


Fig.  356. — Rectus  drawn  inward.     Posterior  layer  of  sheath  and  transversalis  fascia 
divided.     Peritoneum   exposed   and   cone   lifted   preparatory  to   dividing. 

other  complications  are  expected;  B,  when  pus,  localized  or  diffused, 
is  a  certainty. 

A.  Incision. — Begin  one  inch  above  or  two  inches  below  the  line 
connecting  the  anterior  superior  iliac  spine  with  the  umbilicus.  The 
incision  crosses  this  line  one-half  inch  to  its  inner  side  of  its  middle 
point  and  follows,  practically,  the  outer  border  of  the  rectus  abdominis. 


0P1  R  \  I  [ON    FOR    Al'i'l  Mm  II  [S. 


\<)'J 


Divide  first  the  skin  and  fa1  and  expose  the  aponeurosis  of  the  ex 
tcrnal  oblique.     Divide  next  the  aponeurosis  and  under  one  lip  is  the 
Mge  nf  the  rectus,  and  under  the  other,  the  transversalis  (Fig.  355). 
S|>lit  the  sheath  of  the  rectus  and  retrat  1  the  edge  of  the  rectus  exposing 
the  transversalis  fascia. 


PlG.  357.     Appendix  and  part  of  cecum  delivered  and  walled  oil  with  gauze. 

Divide   the   transversalis   fascia,    exposing   the    subperitoneal    fat 

and  pick  up  a  fold  of  the  peritoneum,  and  divide  it,  turning  the  cutting 
edge  of  the  knife  away  from  the  abdomen  (Fig.  356).  Usually  the 
ureal  omentum  will  bulge  into  the  wound  after  the  peritoneal  incision 


5°o 


APPENDICITIS.      PURULENT   PERITONITIS. 


is  enlarged.     Replace  the  omentum  and,  if  necessary,  hold  it  with  a 
gauze  pad. 

Next  introduce  a  finger  and  feel  for  the  cecum,  which  will  be  rec- 
ognized by  its  bands,  and  pull  it  up  into  the  wound  until  the  base 


Fig.  3  5 8. — Peritoneal  cuff  turned  back;  appendix  ligated  and  amputated. 

of  the  appendix  can  be  seen.  The  appendix  may  be  adherent,  and 
the  adhesions  should  be  broken  up  very  gently.  Once  the  appendix 
is  freed,  it  is  to  be  brought  up  out  of  the  wound  and  the  cecum  re- 
turned to  the  abdominal  cavity  and  walled  off  with  gauze  pads 
(Fig-  357)- 


OP]  R  VTION     li  >R     \ri'l  Mi|«  I  \l      \I;m  I  SS. 


501 


Tie  off  the  meso  appendix  with  catgut,  and  cut  it  away  from  the 
appendix  close  to  its  line  of  attachment. 

An  incision  Is  now  carried  around  the  base  of  the  appendix,  dividing 
only  the  serous  coat,  which  is  stripped  back  toward  the  ce<  urn,  forming 
a  peritonea]  cuff  (Fig.  358).  The  appendix  is  now  ligated  and  1  ut  off, 
the  mucous  stump  touched  with  carbolic  arid  and  then  with  alcohol. 
J"he  peritonea]  cuff  is  drawn  over  the  stump  and  sutured.  The  stump 
i^  now  invaginated  and  buried  with  a  row  of  Lembert  sutures.  The 
gauze  pads  are  removed  with  the  exception  of  one,  which  covers  the 
cecum  until  the  last  stitches  are  placed  in  the  peritoneum.  Repair  by 
separate  lines  of  suture  the  peritoneum,  transversalis,  aponeurosis,  and 
skin.      Drainage  is  unnecessary. 

B.  'flic  incision,  four  inches  long,  is  a  finger's  breadth  to  the  inside 
of  the  anterior  superior  iliac  spine,  with  its  middle  corresponding  to 
the  spine  (Fig.  359). 


/ 


I 


;9. — Appenilicial  incision.      (Veau.) 


Pig.  360. — The  external  oblique  divided  : 
the  internal  oblique  exposed.      (Vmw.) 


The  first  incision  traverses  the  skin  and  superficial  fascia,  which 
are  likely  to  lie  very  vascular  in  such  a  case.  The  external  oblique 
appears,    its    fibers   parallel    with    the    incision.      Divide    it    the    whole 

length  of  the  wound  and  catch  the  edges  with  forceps  which  will  serve 
as  retractors  (Fig.  360). 


5°2 


APPENDICITIS.      PURULENT   PERITONITIS. 


Next  divide  the  internal  oblique  and  transversalis  muscles,  whose 
fibers  run  transversely.  The  layer  is  thick,  and  several  vessels  will 
need  to  be  caught  (Fig.  361). 

Retract  these  layers  and  the  transversalis  fascia  is  exposed.  This 
you  divide,  bringing  into  view  the  peritoneum.  If  you  do  not  expect 
complications,  make  the  primary  incision  shorter,  and  split  each 
muscular  layer  in  the  direction  of  its  fibers. 

Catch  up  a  fold  with  the  forceps,  and  divide  its  base  with  the  scissors 
(Fig.  362).     From  the  small  orifice  thus  created,  there  flows  a  sero- 


Fig.  361. — The  two  oblique  muscles  incised,    Fig.  362.— ^Showing  the  three  muscular  layers 
the  transversalis  exposed.      (Veau.)  and  the  peritoneum  incised.      (Veau.) 

or  purulent  fluid.  Enlarge  the  peritoneal  opening  and  hold  back  the 
intestine  with  compresses.  Examine  the  cavity.  It  may  be  that  the 
omentum,  thickened  and  infiltrated,  will  cover  the  field,  but  do  not  dis- 
turb it. 

Follow  with  the  index  finger  the  wall  of  the  fossa  until  the  cecum 
is  reached.  Wiping  out  the  cavity,  you  may  be  able  to  see  the  bands 
of  the  cecum,  which  are  to  be  followed  downward  by  sight  and  touch, 
for  they  lead  to  the  appendix. 

Remove  the  appendix  if  possible.  You  may  not  be  able  to  find  it, 
but  do  not  prolong  the  search  and  certainly  do  not  break  up  adhesions 
in  this  search. 


OP]  R  VTION    l  OR    M'l'l  NDICIAL   Ai;s<  I  SS. 


503 


Winn  ii  is  Located,  gently  draw  it  to  the  surface.  It  is  exceedingly 
friable  and  should  nol  be  ruptured.  Throw  a  catgul  ligature  about 
its  base  close  up  to  the  cecum  and  tie  moderately  tight  (Fig.  363). 

Amputate  the  appendix,  and  if  there  is  no  bleeding  cut  the  ligature 
short.     Determine  now  the  character  <>f  the  suppuration,  whether  1  ir 
cumscribed  or  diffuse  t  Fig.  36  | ). 

(a)  It  is  Circumscribed.  —  Wipe  out  the  cavity  very  carefully  with 
sterile  gauze.  Do  not  irrigate.  Place  a  drainage-tube  upward  toward 
the  diaphragm  (Fig.  365).     Do  not  use  violence.     There  a  new  col 


Fie..  363. — Throwing  a  ligature  around  base  of  sloughing  appendix.      (Veau.) 


lection  of  pus  may  be  found.  Pass  a  second  drainage-tube  in  the 
same  manner  down  into  the  pelvic  cavity.  This  is  the  most  im- 
portant, for  the  fluids  tend  to  collect  there.  Leave  the  third  in  the 
iliac  fossa  and  (he  fourth  directed  toward  the  middle  of  the  abdomen. 
Sec  ure  each  with  a  safety-pin.  Suture  up  to  the  drainage-tubes,  so 
that  the  opening  will  be  only  large  enough  to  accommodate  the  tubes. 
If  the  patient  is  a  female,  after  wiping  out  the  cavity  carefully,  a 
counteropening  may  be  made  into  the  vagina  in  favorable  cases,  and 
with  efficient  drainage  secured   by  that  route,   the  abdomen   may  be 

completely  closed. 


5°4 


APPENDICITIS.      PURULENT  PERITONITIS. 


In  many  cases  even  without  such  drainage,  the  abdomen  may  be 
closed  after  cleansing  the  cavity,  but  it  cannot  be  advised  in  the  emerg- 
ency work  of  general  practice. 

(b)  The  Suppuration  is  Diffuse. — Hurriedly  make  an  incision  from 
the  umbilicus  downward  for  a  couple  of  inches,  which  is  sufficient. 
When  the  peritoneum  is  opened,  the  fingers  can  touch  through  the  two 
openings. 


Fig.  364. — Diagram  showing  directions  the  pus  may  extend. 
B.  Pelvic.     C.  Iliac.      (Veau.) 


A.  Sub-hepatic; 


If  the  pus  seems  to  have  reached  into  the  left  side,  make  a  third 
incision  over  the  left  iliac  fossa.  Through  these  incisions  irrigate 
the  abdominal  cavity  with  normal  salt  solution,  using  plenty,  three 
of  four  quarts,  and  continue  the  irrigation  until  the  fluid  flows  out 
clear.  Unless  it  be  complete,  reaching  every  part  of  the  cavity, 
irrigation  had  better  be  dispensed  with.  The  additional  incisions 
may  even  be  unnecessary  if  the  following  treatment  is  pursued. 


SALINl     I  \i  \i  V    FOR    DIFFUSE   SUPP1  R  \  I  l""-. 


505 


The   patient   is  now    put   in   the  Fowler  position   and   ,1    continuous 

rectal  enema  of  normal  salt  solution  arranged  for.    The  purpose  of 

this  treatment,  instituted  by  Murphy  with  such  signal  success,  is  to 
secure  a  constant  saline  lavage  of  the  peritoneal  cavity.  In  other 
words,  the  fluid  passess  from  the  bowel  into  the  peritoneal  cavity, 
accomplishes  its  healing  mission,  and  drains  out  through  the  ab- 
dominal  wound. 

The  fluid  should  be  maintained  at  a  temperature  of   ioo°  F.,  and 
should  bi'  allowed  to  flow    into  the  rectum  at  the  rate  of  one  pint  per 


^1>  "\ 

Fig.  365. — Placing  a  tube  in  the  sub-hepatic  space.     (Vcau.) 

hour  or  thereabout.  The  patient's  sensation  should  be  consulted. 
If  there  is  a  feeling  of  tightness  and  distress,  the  flow  should  be  lessened. 
After  two  or  three  quarts  have  been  introduced,  the  flow  should  be 
shut  off  for  an  hour  or  two.  The  injections  may  be  continued  one  to 
three  days. 

Moynihan  reviews  his  experiences  with  this  treatment  (Lancet, 
Aug.  17,  1907)  and  concludes  that  it  has  exceptional  value.  He 
insists  upon  attention  to  the  details  of  administration  and  describes 
the  methods  found  most  useful.  The  largest  quantity  of  the  solution 
taken   by  any  of  his   patients  was  sixteen   pints   for   the   first  twenty- 


506  APPENDICITIS.      PURULENT   PERITONITIS. 

four  hours,  and  a  total  of  twenty-nine  pints  in  three  days.  He  em- 
phasizes the  character  of  improvement  in  the  appearance  of  the 
patient,  in  his  pulse  and  temperature,  and  in  the  action  of  kidneys 
and  skin. 

The  plan  pursued  by  others  aims  to  secure  drainage  by  means  of 
tubes  passed  in  various  directions  into  the  intestinal  mass  and  into 
the  pelvic  cavity.  Under  these  circumstances,  the  enemas  of  normal 
salt  solution  should  be  used  at  intervals  and  the  dressings  changed 
on  the  second  day.  On  the  fifth  day,  the  tubes  should  be  removed, 
cleansed  and  replaced  exactly  as  before.  The  patient  must  not  strain 
while  this  change  is  being  made  and  children  may  need  to  be  given 
a  few  whiffs  of  chloroform.  Cleanse  the  drainage-tubes  every  third 
day,  gradually  shortening  them  as  granulation  proceeds. 

If  a  new  focus  of  infection  forms,  if  the  temperature  reaches  beyond 
ioi°  in  the  evening  for  two  or  three  evenings,  no  matter  what  it  was  in 
the  morning,  one  may  be  sure  of  suppuration  somewhere.  It  will  be 
necessary  to  reoperate  and  reestablish  drainage. 

Septic  peritonitis,  originating  elsewhere  than  the  appendix,  ought 
to  be  similarly  treated,  but  the  results  are  so  discouraging  that  the 
operation  cannot  be  urged  upon  the  general  practitioner,  however 
advisable  it  may  be  in  hospital  practice. 

The  principle  of  treatment  is  the  same.  Make  a  median  incision 
below  the  umbilicus  and  search  for  the  cause.  It  may  originate  from 
a  ruptured  Fallopian  tube,  it  may  follow  perforation  of  the  stomach 
or  duodenum,  and  the  break  must  be  located  and  repaired.  It  may 
follow  the  perforation  of  typhoid  fever  and  for  this  condition,  the 
operation  will  be  done  more  and  more  as  time  goes  by.  The  present 
status  of  this  procedure  is  probably  fairly  stated  in  the  Pennsylvania 
Medical  Journal,  Feb.  i,  1908: 

Hayes,  of  Pittsburg,  reports  a  series  of  thirty-eight  cases  with  four- 
teen recoveries  (36.8  per  cent.).  He  operates  under  local  anesthesia 
(cocaine  1/2  per  cent.)  and  flushes  the  cavity  with  normal  salt  solution. 
He  recommends  that  the  perforated  bowel  be  resected,  regarding 
attempts  at  repair  as  futile. 

Mitchell,  of  Philadelphia,  reporting  on  the  experiences  of  the 
Pennsylvania  Hospital,  gives  23  per  cent,  of  recoveries.     He  recom- 


OP]  B  \  I  l"\    I  OB    l  1  I'll « > 1 1  >    IM  RPOB  VI  [ON.  507 

mends  opening  through  the  outer  border  of  the  rectus  muscle  under 
ether  anesthesia  and  with  subsequent  repair  of  the  perforations.  It 
too  Dumerous,  he  advises  packing  off  die  injured  portion  oi  the  bowel 
from  the  general  cavity  by  gauze  compresses. 

Laplace  remarks  that  usually  the  surgeon  is  not  tailed  until  the 
patient  is  in  full  shock  and  a  general  peritonitis  is  already  begun. 
He  favors  resection  of  the  ulcer-bearing  area  of  the  ileum. 

Gerster,  of  New  York,  before  the  1909  Congress  at  Budapest,  sum- 
marizes the  treatment  of  diffuse  free  progressive  peritonitis  thus:  (1) 
Preliminary  lavage  of  the  stomach;  (2)  anesthesia  by  nitrous-oxid 
gas  followed  by  ether;  (3)  rapid  exposure  of  primary  focus  of  infec- 
tion; (  ()  stoppage  of  viscera]  leak  by  suture  or  tamponade;  (5)  gentle- 
ness and  rapidity  of  procedure,  avoidance  of  friction  by  wiping,  etc.; 
(6)  no  irrigation;  (7)  soft  rubber-tube  drainage  of  right  iliac  fossa  and, 
if  necessary,  of  Douglas'  pouch;  (8)  closure  of  external  wound  by 
three  layers  of  suture;  (9)  for  paralytic  ileus  repeated  gastric  lavage, 
low  and  high  enemata,  or  systematic  rectal  lavage,  enterotomy  by 
stab  done  in  intractable  cases  only;  (10)  rational  administration  of 
opiates;  (11)  withholding  of  all  ingesta  while  vomiting  is  present; 
(1:)  Murphy's  proctoclysis;  (13)  Fowler's  position;  (14)  early  incision 
and  drainage  of  secondary  abscesses;  (15)  laxatives,  calomel  and  salts, 
to  be  given  only  after  cessation  of  vomiting;  and  (16)  tampons  used  for 
walling  off  necrosed  areas  not  to  be  disturbed  without  necessity  till  they 
become  detached  of  themselves. 


CHAPTER  IX. 
ACUTE  INTESTINAL  OBSTRUCTION. 

Acute  occlusion  of  the  intesinal  canal  is  a  condition  always  to  be 
dreaded,  for  it  begins  suddenly  and  unexpectedly  and,  unless  relieved, 
hurries  to  a  fatal  issue,  due  either  to  shock  or  sepsis.  Perhaps,  as 
Bloodgood  says,  the  condition  is  not  a  frequent  one,  yet,  none 
the  less,  it  is  an  emergency  whose  character  must  be  thoroughly 
understood. 

But  for  that  matter  its  character  is  variable,  depending  upon  the 
cause.  To  simplify  the  subject,  the  obstruction  due  to  strangulated 
hernia  is  not  considered  here,  for  in  such  cases  the  cause  of  the  obstruc- 
tion is  quite  obvious;  nor  need  we  consider  postoperative  ileus,  for  it 
has  a  pathology  of  its  own;  again  the  obstruction  which  may  accompany 
appendicitis  is  in  a  class  by  itself.  The  acute  obstruction  to  be  studied 
includes  those  changes  in  the  form  or  direction  of  the  bowel  or  those 
accumulations  within  its  lumen  which  completely  and  suddenly  dam 
the  fecal  current.  Whether  it  be  a  kink  or  twist  in  the  gut;  a  volvulus 
or  intussusception,  an  adhesive  or  constricting  band,  relict  of  a  former 
peritonitis;  an  accumulation  of  gall-stones  or  a  cancer:  whatever  the 
source  of  the  obstruction,  the  danger  arises,  as  has  been  said,  from 
two  sources — shock  and  sepsis.  By  far  the  lesser  of  these  two  evils  is 
shock  In  many  cases  it  may  be  absent,  and  even  when  it  is  the  domi- 
nant feature  early  in  the  attack,  it  may  gradually  subside.  The 
sympathetic  plexuses  seem  able  to  regain  their  balance  and  adjust 
themselves  to  new  conditions.  For  this  reason  attacks,  which  begin 
with  collapse,  often  seem  to  improve  in  a  short  time.  But  such  im- 
provement is  deceptive,  for  sepsis  pursues  its  insidious  course,  the 
bowel  becomes  more  distended,  its  peritoneal  coat  more  permeable, 
and  so  the  intestinal  bacteria  find  their  way  into  the  peritoneal  cavity 
and  their  toxins  into  the  blood.  It  is  stercoremia,  therefore,  which  is 
to  be  dreaded,  for  there  is  no  way  to  measure  its  progress  with  any 
certainty. 

508 


DIAGNOSIS    01     \«  i   li     OBS'l  I'M   l  ion.  509 

J.  R.  Eastman  reports  a  case  which  illustrates  the  deceptive  char- 
acter of  many  cases  of  obstrui  tion.  The  patient  had  undergone,  some 
lears  before,  three  various  abdominal  operations.  Tin-  attack  came 
on  suddenly,  and  on  the  third  day  the  vomiting  became  stercoraceous. 
In  preparing  for  the  operation,  high  enemas  were  given,  followed  by 
escape  of  flatus.  The  operation  was  deferred,  as  the  patient  continued 
apparently  to  improve,  the  bowels  moving,  gas  escaping  freely,  and 
the  patient  feeling  quite  comfortable.  Two  days  after,  however,  the 
fecal  vomiting  reappeared  and  with  it  all  the  ominous  signs  of  ob- 
struction. At  the  operation,  four  inches  of  small  intestine,  adherent 
in  an  inflammatory  mass,  was  found  to  be  gangrenous.  Resection, 
anastomosis,  recovery.  It  is  to  be  noted  that  the  bowels  had  moved 
though  the  gut  was  strangulated  and  gangrenous,  the  gas  and  fecal 
matter  undoubtedly  passing  the  point  of  strangulation.  |  Indianapolis 
Medical  Journal,  July  15,  1909.) 

The  group  of  symptoms  constitutes  a  very  definite  clinical  picture: 
(a)  pain,  (b)  tympanites,  (c)  vomiting,  (d)  constipation,  and  (e) 
collapse. 

(a)  The  pain  develops  suddenly  and  severely,  often  following 
some  violent  exertion,  and  takes  the  form  of  paroxysmal  colic.  There 
is  localized  tenderness. 

(b)  Tympanites  is  marked,  the  whole  abdomen  being  distended, 
and  often,  on  this  account,  the  respiration  and  circulation  are  impaired. 
Peristalsis  is  exaggerated,  and  the  violent  movements  of  the  bowel 
may  often  be  noted  through  the  abdominal  wall.  At  the  site  of  the 
greatest  tenderness,  a  tumor  may  be  found. 

(c)  There  is  often  at  first  a  rumbling  of  the  bowels  and  nausea, 
soon  followed  by  an  incessant  and  distressing  vomiting,  at  first  gastric 
and  finally  fecal. 

(d)  Constipation  is  a  constant  feature,  though  at  first  there  may 
be  some  movement  from  the  lower  bowel.  In  intussusception  there 
is  often  all  through  the  attack  some  discharge  of  bloody  mucus  and 
gas.  This  may  be  the  case,  too,  in  strangulation  near  the  pylorus,  but 
in  such  a  case,  the  extreme  distention  of  the  stomach  and  the  violence 
of  its  movements  suggest  the  nature  of  the  difficulty. 

(e)  Collapse  is  imminent  from  the  first,  and  is  indicated   by   the 


5IO  ACUTE    INTESTINAL    OBSTRUCTION. 

weak,  thready  pulse,  the  rapid  breathing,  the  pale,  pinched  features, 
and  the  anxious  expression. 

These  are  the  symptoms,  whatever  the  form  of  the  acute  obstruc- 
tion, whether  it  be  strangulation,  intussusception,  or  volvulus,  and 
very  rarely  can  the  form  of  the  obstruction  be  definitely  determined 
before  the  operation  or  postmortem. 

Certain  factors  make  one  of  the  conditions  the  most  probable.  If 
it  is  a  child  under  ten  years  of  age,  it  is  almost  certain  to  be  intussus- 
ception; if  there  have  been  previous  attacks  of  some  form  of  peritonitis, 
strangulating  bands  of  adhesion  are  likely  to  be  present;  if  the  patient 
is  forty  or  fifty  years  of  age,  with  a  history  of  constipation,  volvulus  | 
suggests  itself. 

In  addition  to  noting  the  symptoms  and  history,  a  careful  search 
must  always  be  made  by  palpation  for  an  abdominal  tumor,  and 
finally  the  investigation  is  terminated  by  rectal  or  vaginal  examination. 

Treatment. — In  the  few  hours  that  must  elapse  before  one  can 
fully  make  up  his  mind  that  it  is  a  case  of  acute  obstruction,  there  are 
certain  things  to  do,  but,  more  especially,  certain  things  not  to  do. 
Do  not  give  purgatives.  This  is  an  axiom  scarcely  necessary  to  re- 
peat. They  can  do  no  good  and  will  most  certainly  do  harm.  Do 
not  give  large  and  repeated  doses  of  morphine.  It  will  help  the 
patient  to  die  easy,  but  in  such  a  case,  it  is  "not  a  remedy  for  the 
patient  but  a  refuge  for  the  doctor."  It  is  doubtful  even  if  it  should  be 
given  at  all.  It  is  possible  that  minute  doses  may  diminish  the  peris- 
talsis, quiet  the  vomiting  to  some  extent,  relieve  the  shock  a  little,  and 
ease  the  pain  measurably  without  masking  the  true  conditions,  but 
under  the  circumstances,  it  is  an  edged  tool.  Give  no  nourishment 
by  mouth.  The  two  measures  likely  to  be  of  the  greatest  benefit 
are  gastric  lavage  and  rectal  injections. 

The  gastric  lavage  may  in  some  measure  diminish  the  vomiting; 
and,  in  case  an  anesthesia  is  necessary,  it  may  prevent  asphyxia  from 
a  gush  of  vomited  matter. 

Rectal  enemas  are  sometimes  effective  in  relieving  the  obstruction, 
but  if  used,  it  must  be  with  the  strict  proviso  that  the  injection  be  done 
carefully.  If  roughly  given,  if  the  fluid  is  thrown  into  the  bowel  with 
too  much  force,  even  if  there  is  no  danger  of  rupturing  the  bowel,  it 


TECHNK     FOB    RECTAL   INJECTION.  511 

at  least  irritates  ii  and  defeats  its  own  purpose.  It  is  likely  it"  the  con- 
dition has  existed  more  than  2 1  hours  the  enemata  will  be  of  no  avail. 

There  is  a  definite  modi-  of  procedure:  put  the  patient  crosswise  in 
led  iii  the  lithotomy  position,  with  the  pelvis  turned  slightly  to  the 

(ight  side.  Anoint  the  anal  region  well  with  vaseline,  and  also  the 
rectal  tube,  which  should  be  of  soft  rubber,  three  or  four  feet  in  length. 
In  the  case  of  an  infant,  a  rubber  catheter  will  serve.  Guide  the 
catheter  with  the  left  index  finger,  and  as  it  enters  the  rectum  direct  it 
backward  at  first  and  then  slightly  to  the  left.  Keep  hold  of  the 
tube  dose  up  to  the  rectum,  the  better  to  control  it.  Push  the  tube  a 
little  at  a  time,  and  if  it  meets  with  the  obstruction,  withdraw  it  slightly, 
and  advance  it  with  a  boring  movement.  Any  force  may  result  in  the 
tube  merely  coiling  up  in  the  rectum,  in  the  meantime  the  doctor  have- 
in^  the  impression  that  it  is  ascending  high  in  the  bowel.  Sometimes 
it  is  advantageous  to  let  the  injection  How  as  soon  as  the  first  part  of 
the  tube  is  introduced,  as  by  that  means  the  rectum  is  dilated  and 
Houston's  valves  are  not  so  likely  to  intercept  the  tube.  The  tube 
must  be  introduced  as  high  as  possible  without  using  force.  In  the 
great  majority  of  cases  it  goes  no  higher  than  the  sigmoid. 

Attach  the  fountain  syringe,  holding  it  low  at  first  and  gradually 
raising  it  to  increase  the  pressure.  It  should  not  be  raised  much 
more  than  three  feet  above  the  patient's  level.  The  quantity  of 
fluid,  either  warm  salt  solution  or  oil,  which  may  be  injected,  varies 
with  the  age,  say  one  pint  for  the  infant  and  four  to  six  quarts  for 
the  adult. 

When  the  injection  is  completed,  withdraw  the  tube  rapidly,  and 
lay  the  patient  back  in  bed.  The  enema  will  be  expelled  sooner  or 
later  with  severe  colicky  pains.  If  ineffective,  it  returns  practically 
clear.  If  it  has  done  good,  it  will  be  accompanied  by  flatus,  and, 
at  the  last,  there  will  be  some  hard  lumps.  The  final  evacuation  may 
lot  take  place  for  some  time,  but  the  escape  of  gas  is  a  good  indication 
that  the  obstruction  has  been  at  least  temporarily  relieved. 

If  this  has  not  done  good,  the  enema  should  be  repeated  with  the 
patient  in  the  knee-chest  position. 

Lejars  recommends  the  "electric  bath"  as  efficacious  in  many  cases, 
but  this  treatment  is  start  civ  applicable  in  general  practice. 


Si2 


ACUTE   INTESTINAL    OBSTRUCTION. 


On  the  whole,  the  treatment  is  surgical;  and  the  doctor  must  have 
it  on  his  conscience  that  if  the  case  is  acute  obstruction,  delay  is  dan- 
gerous or  even  fatal.  The  point  is  to  make  the  diagnosis  quickly, 
and  when  that  is  made,  there  is  only  one  thing  to  do,  operate. 

The  practitioner  will  hesitate  between  two  procedures,  median 
laparotomy  and  artificial  anus. 

Median  laparotomy  is  the  ideal  operation.     It  only  is  curative,  for 

the  cause  of  the  obstruction  is  found  and  relieved;  but  it  is  delicate* and 

dangerous.     These  are  the  conditions  which 

Veau   formulates,   under   which   alone  the 

doctor  must  undertake  it: 

(a)  The  operator  must  be  experienced 
and  resourceful,  for  it  is  often  difficult  to 
locate  the  cause  and  equally  difficult  to 
remove  it,  and  the  distended  bowel  is 
always  a  source  of  embarrassment. 

(b)  The   operation   must  be   conducted 
fig.  366.— intussusception.       where  there  are  the  surgical  accessories  and 

capable  assistants. 

(c)  The  diagnosis  must  have  been  perfected,  so  that  the  operator 
knows  about  what  he  will  have  to  do. 

(d)  The  patient  must  be  vigorous  and  able  to  stand  a  tedious  and 
prolonged  operation. 

These  conditions  are  nearly  always  lacking  when  the  doctor  is 
thrown  absolutely  upon  his  own  resources,  so  it  may  be  laid  down  as  a 
rule  that  the  general  practitioner  must  choose  the  second  procedure. 

An  artificial  anus  will  usually  save  the  patient's  life  and  is  within 
the  skill  of  any  doctor  under  almost  any  circumstance.     After  th 
patient  has  later  regained  his  strength,  the  operation  necessary  tc 
complete  a  cure  may  be  undertaken.     It  will  not  be  an  emergency 
operation,  and  the  time  and  place  may  be  chosen. 

To  make  a  temporary  artificial  anus  will  be  the  proper  procedure 
under  the  circumstances  indicated.  There  is  a  single  notable  ex- 
ception: if  the  patient  is  a  child  with  an  undoubted  attack  of  intussus- 
ception, and  if  the  enemas  have  failed  to  give  relief,  it  is  imperative; 
to  do  a  laparotomy  (Fig.  366). 


I'   ii  ssi  Si  i  PTION.  513 

LAPAROTOMY    FOR    l\  II  SSDSC1  PTION. 

A  case  reported  by  Estes  (American  Journal  of  Surgery,  August, 
1906)  illustrates  the  subject  and  emphasizes  the  danger  of  expei  tant 

treatment. 

A  girl  of  three  years  in  fair  health,  three  days  before  had  been  seized 
with  violent  abdominal  pains  with  straining  and  tenesmus.  At 
first  the  passages  were  fecal  and  then  mucous,  tinged  with  blood.  She 
had  intervals  of  apparent  ease  when  she  would  play  with  her  toys  and 
ask  for  something  to  eat.  After  three  days'  treatment  by  enemas  and 
light  laxatives,  she  developed  signs  of  complete  obstruction.  The 
abdomen  was  distended,  vomiting  frequent  and  at  last  feculent;  there- 
was  persistent  pain,  rapid,  weak  pulse,  and  general  weakness.  At 
pis  lime  Estes  was  called  and  found  a  very  pale,  emaciated,  weak, 
suffering  baby,  with  pulse  130,  and  temperature  1010.  She  was 
vomiting  every  half-hour.  No  distinct  tumor  could  be  felt,  but  there 
was  some  thickening  in  the  right  iliac  region.  Through  that  night, 
while  preparing  for  the  operation  next  morning,  she  was  given  some 
krychnia  and  morphia  and  saline  enemas,  which  produced  an 
improvement. 

Operation — median  incision.  A  hand  passed  into  the  right  iliac 
fossae  located  the  sausage-shaped  tumor  of  an  ileo-cecal  intussuscep- 
tion. Turning  the  child  to  get  the  intestines  out  of  the  way,  gentle 
milking  motions  were  made  and  almost  immediately  the  intussuscep- 
tion was  reduced.  Inspection  showed  a  very  much  thickened  and 
inflamed  section  of  the  ileum  about  six  inches  long.  It  was  decided 
not  to  exsect  the  injured  gut.  The  torn  border  of  the  mesentery  was 
sutured,  the  peritoneal  coat  bathed  with  hot  saline  solution,  dried, 
sprinkled  with  aristol  and  replaced,  and  the  abdomen  rapidly  closed. 
The  child  made  a  rapid  and  uninterrupted  recovery  and  has  been 
quite  well  ever  since. 

The  principal  steps  in  the  operation  are  as  follows: 

(1)  Median   laparotomy.     Be   careful   in  opening   the  peritoneum 
not   to  wound   the  distended  bowel.     Expect  to  find  trouble  in  the 
management  of  the  bowel.     A  skillful  assistant  is  a  great  comfort  in 
this  matter. 
33 


5*4 


ACUTE   INTESTINAL   OBSTRUCTION. 


(2)  Search  for  the  obstruction.  The  obstruction  is  usually  easily- 
found  in  intussusception.  After  the  abdomen  is  opened,  proceed 
directly  to  the  right  iliac  fossa,  having  no  fear  to  introduce  the  whole 
hand,  if  gently  done.  In  any  case  the  cecum  is  first  to  be  examined, 
for  by  its  condition  one  can  determine  whether  the  obstruction  is  in 
the  large  or  small  intestine. 

The  sausage-shaped  tumor  (in  the  case  of  intussusception)  is 
pulled  up  into  the  wound  and  its  topography  carefully  noted  and  its 


lt\ 

. 

\ 

\ 

\ 

Fig.  367. — Senn's  method  of  performing  taxis  in  reducing  an  invagination. 

integrity  determined.  If  there  are  no  adhesions,  if  there  are  no 
appearances  of  gangrene;  in  other  words,  if  the  accident  is  recent, 
try  to  reduce  the  bowel. 

(3)  Disinvaginate,  following  the  procedure  of  Senn,  which  has 
for  its  aim  first  to  reduce  the  edema.  This  is  to  be  accomplished  by 
steady  and  uninterrupted  manual  compression  of  the  tumor. 

As  soon  as  the  swelling  is  reduced,  grasp  the  bowel  below  the  tumor 
and  press  gently  but  firmly  against  the  apex  of  the  intussusceptum, 
at  the  same  time  making  easy  traction  at  the  other  end  (Fig.  367).  Re- 
member it  is  easy  to  tear  the  bowel  or  mesentery. 


RESECTION    I  l  >\<    INTUSS1  Si  M'l  tO!  , 


5IS 


Winn  the  bowel  is  reduced,  examine  again  for  gangrene.  If 
ihcrc  are  points  of  disintegration,  cover  them  in  by  Lembert  sutures. 
li'  the  whole  segment  of  the  bowel  is  gangrenous,  it  must  be  reset  ted; 
or  it"  doubtful,  retained  in  the  wound  for  further  inspection.  If  the 
bow el  is  not  impaired,  wash  and  return;  and  the  operal ion  is  1  ompleted 
by  the  repair  of  the  abdominal  wall. 

If,  as  Scnn  says,  repealed  attempts  at  reduction  fail,  one  of  two  <  ourses 
must  be   pursued:  the  establishment  of  an  intestinal  anastomosis  or 


I'i<..     368.  —  Intussusceptum    exposed. 
(Gmbc.) 


I"ir..  369. — Intussusceptum  resected. 
(Guibe.) 


resection  of  the  invaginated  portion;  but  the  latter,  on  account  of  the 
time  required,  must  not  be  undertaken  unless  the  invaginated  parts  are 
gangrenous. 

The  anastomosis  between  the  parts  of  the  bowel  above  and  below  the 
invagination  may  be  accomplished  by  suture  or  the  Murphy  button. 
The  technic  of  resection  of  the  invaginated  portion  is  represented  in 
Figures  368,  369,  370,  and  371. 

A  case  reported  by  Edmund  Clark,  of  Indianapolis,  in  a  way  typifies 
the  condition  and  emphasizes  the  points  which  serve  to  distinguish 
intussusception  from  other  forms  of  obstruction  (Ind.  Med.  Jour., 
March,  1908).     The  patient,  nine  months  old,  previously  well,  began 


5i6 


ACUTE    INTESTINAL    OBSTRUCTION. 


to  have  fits  of  crying.  In  a  few  hours,  it  began  to  have  frequent  bowel 
movements  which  contained  blood  and  mucus.  A  sausage-shaped 
tumor  was  discovered.  On  the  second  day  the  child  was  brought 
to  Clark  and  its  appearance  was  such  as  to  suggest  there  was  nothing 
serious  the  matter  with  it.  But  such  appearances  may  be  deceptive. 
An  examination  demonstrated  the  necessity  for  operation. 

By  means  of  a  median  incision  two  and  one-half  inches  long,  the 


Fig.  370. — Anastomosis  after  resection. 
(Guibe.) 


Fig.  371. — Repair  of  the  bowel  and 
application  of  Lembert  sutures  over 
the  site  of  anastomosis.      (Guibe.) 


tumor  in  the-  right  iliac  region  was  reached  and  delivered.  Three 
feet  of  the  ileum  with  its  mesentery  was  found  in  the  cecum.  The 
mass  was  dark  red. but  not  gangrenous.  Though  tightly  constricted, 
it  was  disinvaginated  without  difficulty.  The  abdomen  was  closed 
without  drainage;  the  whole  operation  lasted  fifteen  minutes.  Re- 
covery was  complete. 

The  predisposing  cause  of  such  attacks  is  often  acute  indigestion. 

The  pain,  which  is  the  first  symptom,  is  often  merely  colicky  at 
first,  but  later  may  be  persistent.  Vomiting  is  common  but  not  nearly 
so  severe  as  in  other  forms  of  obstruction,  nor  does  it  appear  so  early. 


s\  I1PT0MS    "I     POSTOPI  K'A  riVE  ILEUS.  5"7 

The  temporary  relief  following  the  vomiting  is  characteristic  of  in- 
tussusception. The  Dearer  the  duodenum  the  invagination  is  situated, 
the  more  severe  the  vomitus.  Rigidity  is  not  an  early  symptom. 
Distention  is  absent  until  late.  Tenderness  is  also  a  late  symptom ; 
indeed,  in  the  early  stages,  pressure  may  give  relief. 

The  presence  of  a  tumor  is  of  great  diagnostic  value;  it  is  usually 
movable,  hard,  and  resistant.  Its  size  gives  no  idea  of  the  amount  of 
bowel  involved.  Tenderness  is  a  severe-  and  early  symptom;  thirst  not 
marked. 

(lark  says,  regarding  the  indications  for  operation,  that  well- 
established  lines  of  treatment,  if  simple  and  non-operative,  die  hard, 
so  that  medical  treatment  of  such  cases  will  only  be  given  up  after 
many  more  lives  are  sacrificed  and  many  more  cases  successfully 
treated  by  laparotomy  reported. 

POSTOPERATIVE  ILEUS. 

The  acute  obstruction  of  the  bowel  which  may — which  too  often 
does — follow  laparotomy  is  one  of  the  tragic  accidents  of  surgery.  An 
operation  of  comparative  simplicity  may  terminate  uneventfully; 
the  patient  rallies  from  the  anesthetic,  seems  to  feel  well,  and  with  the 
family  is  happy  at  the  thought  of  danger  passed.  Twenty-four  hours 
pass  and  it  is  noticed  that  the  temperature  falls  to  subnormal  perhaps. 
and  then  begins  slowly  to  rise.  The  pulse,  at  first  90  to  100  and  of 
fair  volume,  slowly  increases  in  rate  while  decreasing  in  force.  The 
patient's  mind,  perfectly  clear  in  the  first  instance,  begins  in  a  little 
while  to  be  disturbed,  and  he  grows  anxious  as  to  the  outcome  or  per- 
haps calmly  forecasts  the  end. 

In  the  meantime  the  tympanites  has  become  marked,  but  no  gas 
basses  per  rectum;  and  there  is  no  sign  of  movement  or  peristalsis, 
in  the  distended  gut.  The  pain  is  not  severe,  the  chief  distress  is  want 
of  air;  the  patient  complains  that  he  cannot  get  a  good  breath;  nausea 
develops,  and  finally  continuous  vomiting.  If,  now,  the  ordinary  means 
of  relief  of  gaseous  distention  fail  and  the  symptoms  do  not  in  any  re- 
spect improve,  one  may  com  hide  that  he  has  to  deal  with  an  intestinal 
paralysis.  In  simple  tympanites  the  pain  is  colicky  in  its  nature,  there 
is  little  disturbance  in  pulse  and  temperature,  the  vomitus  is  more 


518  ACUTE    INTESTINAL    OBSTRUCTION. 

nearly  normal  in  character.  But  in  spite  of  these  distinguishing 
features,  it  may  be  impossible  to  say,  during  the  first  few  hours,  whether 
the  obstruction  is  serious  or  not.  In  any  event,  certain  measures  should 
be  employed:  If  there  is  much  nausea  or  any  evidence  of  gastric  dilata- 
tion the  stomach  should  be  washed  out  and  1/20  grain  calomel  given 
every  half-hour  for  at  least  ten  doses.  At  the  other  end  of  the  alimen- 
tary tube,  the  attempt  at  relief  is  begun  with  an  ordinary  soapsuds 
enema.  If  no  flatus  passes,  a  Watkin's  enema  is  next  to  be  tried,  or  one 
which  consists  of 

Magnesia  sulphate, 
Glycerin,  aa      §ij 

Turpentine,  3j 

A  large  tube  should  be  employed,  but  no  effort  made  to  introduce  it 
high.  Elevate  the  hips  and  inject  the  fluid  slowly,  and  thus  let  it  find 
its  own  way  up  the  bowel.  If  gastric  lavage  and  the  persistent  use 
of  enemas  fail  to  give  any  relief,  if  the  judicious  use  of  hypodermic  in- 
jections of  morphine  and  atropia,  eserine,  and  strychnia  are  without 
effect  to  awaken  the  intestine  or  to  sustain  the  patient's  vitality,  the 
only  thing  left  which  offers  any  hope  is  an  enterostomy.  This  may  be 
done  under  local  anesthesia.  The  bowel  through  this  opening  is  to  be 
kept  washed  out  with  normal  salt  solution.  By  this  means  the  toxemia 
may  be  kept  under  control  until  the  patient's  forces  rally. 

But,  after  all,  the  chief  treatment  of  postoperative  intestinal  paralysis 
is  prophylactic  and  preventive.  By  washing  out  the  stomach,  by 
having  the  bowel  well  emptied  with  castor  oil,  by  treating  the  exposed 
gut  with  scrupulous  care,  one  may  hope  to  reduce  these  accidents  to  the 
minimum.  Slight  traumatisms  of  the  mesentery  in  the  course  of  the 
operation,  slight  infections  introduced  in  the  clean  cases  are  at  the 
bottom  of  these  surgical  disasters.  If  they  result  from  infections  al- 
ready fixed  upon  the  peritoneum  before  operation,  the  surgeon  may 
have  a  balm  for  his  conscience  but  no  excuse  to  relax  his  precautions. 

In  all  operations  in  which  there  is  a  diffused  peritonitis  in  order  to 
prevent  postoperative  ileus,  Heile  injects  50  to  100  c.c.  castor  oil  in  a 
loop  of  the  small  intestine.  The  puncture  of  the  gut  is  closed  by  a 
small  silk  suture.  He  claims  excellent  results.  (Zeitblatt  f.  Chirurg., 
Leipsic,  July  31,  1909.) 


CHAPTER  X. 

ARTIFICIAL  ANUS:  TEMPORARY;  PERMANENT. 

TEMPORARY  ARTIFICIAL  ANUS— ENTEROSTOM  Y. 

An  acute  obstruction  of  the  bowel  may  necessitate  a  temporary 
drainage  through  the  abdominal  wall.  This  will  be  the  case  when 
circumstances  such  as  environment,  lack  of  experience,  assistance,  or 
Equipment  preclude  a  Laparotomy;  or  even  when  a  laparotomy  is  done 
and  it  is  found  impossible  at  the  time  to  remove  the  cause. 

F.nterostomy  is  therefore  a  life-saving  operation  which  every  practi- 
tioner must  know  how  to  perform. 

The  operation  proposes  opening  the  abdomen,  anchoring  a  loop  of 
intestine  in  the  abdominal  wound  and  opening  this  loop  to  secure 
drainage.  The  incision  will  be  made  ordinarily  in  the  right  iliac  fossa 
and  the  opening  in  the  bowel  made  above  the  obstruction.  For  that 
matter,  one  need  scarcely  fear  that  he  will  open  into  the  bowel  below 
the  constriction,  for  it  is  only  the  distended  portion  that  will  present. 
It  is  preferable  to  open  the  cecum,  but  if  it  is  not  available,  whatever 
loop  presents  will  do. 

No  special  instruments  are  required.  It  is  a  good  idea  to  have 
several  needles  already  threaded  with  silk  No.  o  or  No.  i.  Local 
anesthesia  may  suffice. 

Incision. — Begin  by  dividing  the  skin  and  fat  along  a  line  two 
fingers'  breadth  from  the  anterior  superior  iliac  spine,  parallel  with 
the  fibers  of  the  external  oblique — an  incision  about  three  inches  long. 
whose  central  point  corresponds  to  the  anterior  superior  iliac  spine 
(  Fig.  372).     Catch  up  the  two  or  three  bleeding  points. 

This  first  incision  exposes  the  external  oblique  (Fig.  360)  and  the 
second  divides  that  muscle  in  the  same  line.  Catch  up  the  edges  of  the 
divided  muscle.  In  the  same  manner,  the  third  incision  divides  the 
internal  oblique  and  transversalis,  and  finally  exposes  a  fibrous  layer. 

519 


520 


ARTIFICIAL  ANUS:      TEMPORARY;    PERMANENT. 


the  transversalis  fascia,  which  is  carefully  divided  in  order  to  reach  the 
peritoneum  (Fig.  362).  Pick  up  a  fold  of  that  membrane  with  the  dis- 
secting forceps  and  incise  it  at  its  base,  remembering  that  the  distended 
bowel  is  in  close  contact  (Fig.  356). 

A  reddish  fluid  escapes  as  soon  as  the  peritoneum  is  opened;  seize 
each  lip  with  forceps  and  enlarge  the  opening,  but  not  to  the  full  extent 
of  the  skin  wound.  Restrain  the  bulging  gut  with  compresses.  In- 
troduce the  index  finger  and  examine  in  various  directions  for  a  source 


Fig.  372. — Trace  of  incisions  for  artificial 
anus:  on  the  right,  temporary;  on  the  left, 
permanent.      (Veau.) 


Fig.  373. — Locating  the  cecum.      (Veau.) 


of  obstruction.  Happily  it  may  be  found  and  relieved  without  loss 
of  time.  Usually,  however,  it  will  not  be  and  one  must  not  persist  in 
his  search  or  effort  at  relief.  Attempt  next  to  locate  the  cecum,  pass- 
ing the  index  finger  down  into  the  iliac  fossa,  following  the  external 
wall  (Fig.  373). 

If  successful  in  locating  it,  pull  it  up  into  the  wound  with  index 
finger  and  thumb  and  hold  it  with  two  artery  forceps.  It  is  easily 
identified  by  the  appendices  epiploicae  and  by  its  bands.  If  the  ce- 
cum cannot  be  reached,  employ  any  loop  which  presents. 

Anchor  the  bowel.     The  bowel  is  sutured  to  the  abdominal  wall 


MOD]     '  II    ANCHORING    mi     BOWEL.  521 

in  this  manner:  Commence  al  one  angle,  passing  the  needle  through 
the  parietal  peritoneum  of  one  side,  through  the  serous  and  muscular 


PlG.     ?74. — Attaching    the    bowel    in    the 
angle  of  the  wound.      {Veau.) 


Fie,.  -575. — Attaching  the  bowel  laterally. 
(Venn.) 


PlG.    .<7<).      Diagram    showing 
disposition  of  suturs.  ( 1  r«o«.  1 


Pig.  .W7- — Opening  of  the  bowel  with  thermo- 
cautery.    (Veau.) 


coats  of  the  bowel,  and  through  the  peritoneum  of  the  opposite  side. 
Tic,  hut  do  not  cut  the  threads  (Fig.  374).     Now  make  on  each  side 

three  or  four  "  U  "  sutures  one-half  inch  apart  in  this  manner:  the  needle 


522 


ARTIFICIAL  ANUS:       TEMPORARY;   PERMANENT. 


passes  through  the  parietal  peritoneum,  the  mucous  and  muscular  | 
coats  of  the  bowel,  and  out  through  the  parietal  peritoneum  of  the 
same  side.  Do  the  same  on  the  opposite  side  (Fig.  375).  Collect  the 
loose  ends  of  the  sutures  of  the  same  kind  in  one  forceps.  In  placing 
the  sutures,  do  not  let  the  protruding  segment  of  bowel  get  folded  or 
wrinkled. 

Suture  the  remaining  angle  in  the  same  manner  as  the  first  and 
complete  the  repair  of  the  peritoneal  wound.     The  loop  of  bowel 


Fig.   378. — Temporary  arti- 
ficial anus.      (Veau.) 


Fig.    379. — Incisions   for   temporary   and 
permanent  artificial  anus.      (Veau.) 


may  not  occupy  all  of  it  and  these  peritoneal  sutures  are  cut  short  at 
once.     (The  relative  position  of  the  sutures  is  represented  in  Fig. 

376.) 

Now  repair  the  superficial  wound  by  interrupted  sutures  in  two 
layers,  one  reuniting  the  muscles;  the  other,  the  skin.  The  opening 
left  immediately  over  the  anchored  gut  is  about  an  inch  in  length. 
Cut  the  threads  short. 

Open  the  bowel.  This  is  reserved  for  the  last,  and  here  the  long 
threads  of  the  lateral  bowel  suture,  left  until  this  time,  are  used  to  pull 
the  bowel  well  into  view  (Fig.  377).  Incise  it  with  the  bistoury  for 
about  an  inch,  and  there  is  an  immediate  escape  of  gas. 

Cut  short  all  the  sutures.     The  bowel  will  not  immediately  empty 


OPERATION    FOR    PERMANENT  ARTIFICIAL  ANUS. 


523 


■self.  It  will  require  possibly  twenty  four  hours,  during  which  time 
the  dressing  should  be  changed  every  half-hour,  after  which  time 
twi<  i-  daily  is   sufficient. 

Remove  the  cutaneous  sutures  on  the  sixth  day,  else  later  they  will 
become  septic.    Apply  ointments  to  the  inflamed  skin. 

When  the  bowel  is  once  emptied,  which  may  require  as  long  as 
twenty-four  hours,  seek  to  locate  the  site  of  the  obstruction  and  to  de 


Fig.  380. — Opening  the  peritoneum.     (Guide.) 

ermine  its  nature.  See  if  an  enema  will  find  exit  at  the  wound  or  if  an 
injection  at  the  wound  will  discharge  per  anum  (Fig.  378).  A  month 
later  when  the  patient  has  regained  his  strength,  if  the  bowel  has  not 
become  normal,  send  him  to  a  specialist. 


PERMANENT  ARTIFICIAL  ANUS. 

This  operation,  palliative  in  the  treatment  of  cancer  of  the  rectum, 
pomes  within  the  scope  of  every  doctor.  It  may  even  be  regarded  as 
an  emergency.     There  may  come  a  time  in  the  history  of  the  case 


524 


ARTIFICIAL  ANUS:      TEMPORARY;   PERMANENT. 


when  the  content  of  the  bowel  can  no  longer  pass  and  the  pain  is  un- 
bearable.    Then  the  operation  will  give  great  relief.     The  patient! 


Fig.  381. — The  sigmoid  flexure  drawn  out  through  the  incision.     Note  the 
appendices  epiploic^.     (Veau.) 


Fig.  382. — A  forceps  used  to  make  an  opening  in  the  mesentery.      (Veau.) 

suffers  little  pain  after  the  operation,  gains  in  weight,  believes  that  he 
is  going  to  get  well,  and  so  dies  happy. 


[NCISIOIM    KOK    PKKMANKN1    ARTIFICIAL  ANUS. 


525 


In  this  case,  the  opening  is  i<>  be  in  the  sigmoid;  it  may  need  to  be 
large.  The  bowel  is  <  ompletely  divided  transversely  .in<l  the  two  ends 
anchored  separately  in  the  wound. 

The  operation  is  besl  (lour  in  two  stages.     In  the  first,  the  sigmoid 


Pig.  383.     Bowel  retained  by  strip  of  iodoform  gauze.     (Veau.) 

is  drawn  out  and  permitted  to  acquire  adhesions.     Subsequently  the 
loop  is  resected. 

First  Stage.  —An  incision  two  inches  in  length  is  made  obliquely 
over  the  left  iliac  fossa,  a  couple  of  fingers'  breadth  within  the  an- 
terior superior  spine.     The  lower  end  of  the  incision  reaches  to  just 
above  the  level  of  the  spine  (Fig.  370).     Dividing  the  skin  and  cellular 
,  there  will  be  some  small  vessels  to  ligate.     The  fibers  of  the 


Pig.  ',Sj.-   Dividing  the  loop  with  the  thermocautery.     (Veau.) 

external  oblique  appear,  running  parallel  with  the  incision.  Separate 
them  in  the  line  and  length  of  the  skin  incision  by  blunt  dissection. 
Widely  separate  the  two  portions  of  the  muscle  with  retractors. 

In    the    bottom    of   the    wound    are   seen    the    liliers   of   the    internal 
dfclique  and   transversalis   which   lie  at   right   angles  to  the  external 


526 


ARTIFICIAL  ANUS:       TEMPORARY;   PERMANENT. 


oblique.  Open  through  them  by  blunt  dissection  in  the  direction  of| 
their  fibers  and  retract  (Fig.  380). 

Divide  the  transversalis  fascia  and  expose  the  peritoneum.  Thisj 
is  opened  and  its  lips  seized  with  the  forceps.     Remove  the  retractors. 

Search  for  the  sigmoid.  Introduce  the  index  finger  into  the  iliac' 
fossa,  following  the  posterior  wall  until  arrested  by  the  meso-sigmoid. 
In  this  manner  locate  the  sigmoid  flexure,  and  with  finger  and  thumb 
draw  it  to  the  surface  by  gentle  but  persistent  traction.     It  can  bq 


Fig.  385.  —  Upper 
orifice  communicates 
with  bowel ;  lower  with 
rectum.      {Veau.) 


Fig.  386. — Permanent  arti- 
ficial anus.  External  opening 
of  bowel  with  spur  leading  to 
rectum.     {Veau.) 


felt  to  yield.  Once  the  loop  is  exposed,  the  only  difficulty  is  overcome 
The  sigmoid  is  identified  by  the  appendices  epiploicae  (Fig.  381). 

jSpread  out  the  gut  and  find  the  least  vascular  part  of  the  exposec 
mesentery  and  this  part  transfix  (Fig.  382)  with  a  closed  forceps 
Withdrawing  the  forceps,  seize  a  roll  of  iodoform  gauze  of  the  calibe 
of  the  index  finger  and  draw  it  into  place.  It  will  hold  the  bowel  ii 
position  (Fig.  383). 

If  the  cutaneous  wound  is  too  large  and  does  not  fit  closely  to  thi 
projecting  loop,  it  may  be  diminished  by  a  suture  or  two. 

Dress  with  sterile  gauze  and  do  not  change  until  ready  to  resect 


PI  KM  \\l   \  I     A  K  I  1 1  I «   I  \l     AM  S.  527 

unless  the  dressing  becomes  loosened  or  soiled.  Keep  the  patient 
on  a  light  diet,  chiefly  milk. 

Second  Stage.  Resect  the  bowel.  On  the  second  or  third  d;iy,  when 
the  bowel  has  acquired  adhesions,  return  with  a  thermo  cautery  and 
artery  forceps;  there  might  he  an  arteriole  to  Ligate.  No  anesthesia  is 
necessary,  for  the  gut  is  quite  insensitive. 

The  thermo  cautery  is  heated  to  a  dark  red  (if  at  a  while  heat,  there 
may  be  a  little  bleeding),  and  with  it  the  bowel  is  completely  divided. 
Do  not  stop  until  the  roll  of  iodoform  gauze  is  completely  exposed. 
The  few  minutes  required  will  necessarily  seem  a  long  time,  but  do  not 
get  disturbed  (Fig.  384).  When  the  section  is  complete,  the  gauze 
may  be  readily  removed  (Veau). 

Apply  a  dry  dressing.  On  the  second  day  give  a  laxative.  After 
a  while  the  patient  will  be  able  to  regulate  his  passages  to  a  degree. 

Through  the  lower  orifice  the  cancer  may  be  douched  and  the  fluids 
will  find  their  way  out  per  anum  (Figs.  385,  386). 

Do  not  neglect  to  warn  the  family  that  the  end  must  come  within 
from  eight  to  fifteen  months.  As  for  the  patient,  it  were  better  to  ease 
his  mind  by  vague  references  to  the  future  closure  of  the  wound  so 
repulsive  to  him. 


CHAPTER  XI. 
STRANGULATED  HERNIA. 

What  doctor  in  general  practice  has  not  had  his  experiences  with 
strangulated  hernia?  And  how  many  have  escaped  the  conviction 
that  it  is  an  emergency  deserving  its  evil  fame  ? 

But,  after  all,  its  sinister  reputation  our  predecessors  have  bequeathed 
us  and,  along  with  it,  interminable  discussions  touching  the  agent  of 
constriction  and  the  indications  for  taxis. 

To-day  we  reverently  lay  aside  those  old  notions,  for  we  know  that 
no  other  equally  dangerous  condition  yields  better  results  to  appro- 
priate treatment.  By  "appropriate  treatment"  is  meant  early  opera- 
tion. The  indications  for  operation  there  is  no  need  to  discuss,  for 
operation  is  always  indicated. 

Taxis  is  an  exceptional  procedure,  permissible  only  as  a  tentative 
measure  under  certain  well-defined  restrictions;  and  even  then  to 
be  used  with  fear,  for  who  can  certainly  tell  that  he  has  not  reduced  a 
gangrenous  and  perforated  gut;  and  who  but  the  most  experienced 
may  not  be  misled  by  certain  forms  of  incomplete  reduction? 

The  danger  from  strangulated  hernia  was  formerly  supposed  to 
arise  solely  from  interference  with  the  circulation  and  the  consequent 
gangrene  of  the  incarcerated  loop,  and  the  attention  was  centered 
chiefly  upon  the  mechanical  element.  It  was  perhaps  legitimate 
upon  that  hypothesis  to  treat  expectantly  or  by  repeated  efforts  at 
taxis  an  incompletely  strangulated  hernia. 

But  now  it  is  definitely  determined  that  the  chief  source  of  danger  is 
septic  absorption,  and  in  a  given  case  long  before  the  incarcerated  bowel 
has  ceased  to  be  viable,  the  patient  may  be  overwhelmed  by  toxins  of 
a  virulent  type.  It  is  this  systemic  poisoning  that  makes  strangulated 
hernia  dangerous,  and  which  especially  makes  the  operation  danger- 
ous.    It  is  for  that  reason  that  procrastination  is  so  often  fatal.     So 

528 


DIAGNOSIS   OF   STRANGULATED    HERNIA.  S-'O 

frequently  it  happens  with  these  atta<  ks  that  after  hours  of  waiting,  or 

after  repeated  efforts  at  reduction,  die  patient  is  finally  turned  over  to 
the  operator;  and  though  the  operation  be  of  short  duration  and  simple. 
let  the  patient  dies,  for  the  reason  that  his  powers  of  resistance  were 
paralyzed  by  sepsis  unsuspected.     He  was  a  veritable  victim  of  delay. 

The  thought  to  be  kept  uppermost,  then,  in  treating  strangulated 
hernia  is  not  so  much  that  the  bowel  is  becoming  gangrenous  as  that 
sepsis  is  imminent. 

The  diagnosis  is  not  difficult,  as  a  rule.  Usually  the  patient  is  known 
to  have  a  hernia;  suddenly  it  becomes  painful  and  irreducible;  the 
bowels  refuse  to  move  and  become  tympanitic;  nausea  and  vomiting 
ensue;  and  there  are  signs  of  circulatory  depression.  The  general 
symptoms  are,  in  fact,  those  of  intestinal  obstruction.  The  face  is 
drawn  and  pinched,  the  lips  white  and  the  eyes  sunken.  There  is  a 
clammy  sweat.  The  symptoms  may  all  be  mild  at  first,  especially 
when  the  obstruction  is  not  complete,  or  in  the  aged  or  debilitated,  or 
if  the  bowel  is  surrounded  by  omentum  which  at  first  bears  the  brunt 
of  the  compression.  It  must  be  kept  in  mind  that  this  mild  onset  may 
be  wholly  deceptive. 

It  may  be  necessary  to  distinguish  between  an  inflamed  and  ob- 
structed irreducible  hernia  on  the  one  hand  and  strangulated  hernia 
upon  the  other;  in  the  first,  pain  and  vomiting  are  not  so  severe,  there 
is  no  collapse,  and  an  impulse  in  coughing  can  always  be  detected.  If 
a  hernia  was  not  before  suspected,  a  careful  examination  for  one  must 
be  made  in  cases  of  intestinal  obstruction.  Small  sciatic  or  obturator 
herniae  are  easily  overlooked.  This  is  likewise  true  of  small  femoral 
hernia  in  fat  subjects. 

Torsion  of  the  spermatic  cord  or  strangulation  of  an  undescended 
testicle  may  simulate  strangulated  hernia,  but  the  indurated  and  very 
painful  inguinal  tumor,  together  with  the  cryptorchism,  should  suggest 
the  nature  of  the  attack. 

As  Senn  says,  the  differential  diagnosis  between  a  suppurative 
lymphadenitis  in  the  groin  and  a  strangulated  inguinal  hernia  may  be 
very  difficult.  He  points  out  the  necessity  for  caution  in  using  the 
knife  if  the  inflammatory  swelling  is  single  and  occupies  the  site  of 
a  femoral  hernia.  In  such  a  case  the  supposed  gland  should  be  ap- 
34 


530  STRANGULATED   HERNIA. 

proached  by  a  careful  dissection.  If  it  proves  to  be  a  hernia  no  harm 
is  done. 

An  accumulation  of  peritoneal  fluid  in  the  imperfectly  closed 
processus  vaginalis  in  the  very  young  may  give  rise  to  symptoms  of 
strangulation,  but  strangulated  hernia  is  rare  in  infants.  In  such 
a  case,  inversion  of  the  patient  for  a  few  minutes  will  empty  the  sac 
and  clear  up  the  diagnosis. 

As  has  been  said  the  indication  for  treatment  is  operation  as  soon  as 
the  diagnosis  is  made.  There  are,  however,  exceptional  instances 
in  which  judicious  efforts  at  taxis  may  be  applied  without  greatly 
prejudicing  the  prognosis.  But  it  is  recommended  without  enthu- 
siasm and  only  out  of  due  respect  to  those  circumstances  of  time 
and  place  which  seem  to  preclude  immediate  herniotomy. 

Taxis  and  operation,  then,  represent  the  sole  measures  of  relief. 
Certainly  no  doctor  at  the  present  time  would  expect  anything  but 
harm  from  the   use  of  drugs. 

As  Senn  says  (Practical  Surgery),  no  modern  physician  would  for 
a  moment  consider  seriously  the  therapeutic  value  of  nauseating 
enemata,  or  the  internal  use  of  relaxing  antispasmodic  remedies,  so 
much  relied  upon  in  facilitating  taxis  before  herniotomy  was  shorn 
of  its  great  mortality  by  the  introduction  of  antiseptic  surgery. 

Taxis. — Taxis,  or  the  reduction  of  a  hernia  by  methodical  manipu- 
lation without  instruments,  is  permissible  only  under  these  circum- 
stances: (a)  The  case  is  seen  soon  after  the  strangulation  began; 
the  hernia  is  of  moderate  size;  the  abdominal  symptoms  are  not 
severe. 

(b)  The  patient  is  an  old  man  debilitated,  manifestly  a  poor  sub- 
ject for  an  operation;  he  has  had  trouble  before;  it  is  only  a  few  hours 
since  his  hernia  became  irreducible. 

Under  these  circumstances  use  taxis,  and  it  will  not  be  dangerous 
if  properly  applied  and  not  repeated.  The  further  proviso  must  be 
made  that  if  it  fails  an  immediate  operation  must  be  done.  In  the 
milder  cases  Senn  advises  that  taxis  may  sometimes  be  facilitated  by 
administering  a  dose  of  opium  and  giving  a  high  enema.  A  full  hot 
bath  in  many  instances  has  an  excellent  effect. 

In  the  severer  cases  a  general  anesthesia  is  always  required.     Before 


PAXIS  FOR  INGUINAL  HERNIA.  53] 

beginning  the  anesthesia  prepare  the  patient   for  operation  so  that 

il"  taxis   fails  no  time   need    l>e   lost   ami    a   single   anothesia   will   Serve 

both  for  the  taxis  and  the  operation.     Chloroform  is  usually  preferable 

to  ether  if  il  is  e\|>e.  led  that  taxis  will  succeed.  It  permits  a  greater 
relaxation. 

Technic  of  Taxis:  Inguinal  Hernia. — Elevate  the  hips,  ilex 
and  separate  the  thighs  in  order  to  relax  the  external  ring.  Grasp 
the  tumor  with  the  right  hand  (hernia  on  right  side)  so  as  to  com- 
press it  uniformly  with  the  tips  of  the  lingers  and  thumb.  Seize  the 
net  k  at  the  external  ring  between  the  thumb  and  forefinger  of  the 
left  hand.  While  the  right  gently  compresses  the  tumor,  the  left 
empties  the  gut  by  stripping  in  the  direction  of  the  external  ring  at 
first,  and  later  along  the  inguinal  canal.  The  sole  aim  of  this  first 
manoeuvre  is  to  empty  the  gut.  The  manipulations  must  be  made 
methodically,  without  interruption  and  without  force.  If  compres- 
sion reveals  the  presence  of  a  doughy  mass,  it  is  omentum,  and  as 
it  probably  occupies  the  lower  part  of  the  sac  it  will  be  better  to  com- 
press nearer  the  neck  in  order  to  deal  more  directly  with  the  intestine. 
Sometimes,  to  make  traction  on  the  tumor  while  the  fingers  at  the 
neck  continue  the  kneading  will  start  the  bowel  contents  toward  the 
abdominal  cavity.  If  the  tumor  under  these  manipulations  grows 
smaller  and  softer,  it  is  some  guarantee  of  success.  When  the  bowel 
is  sufficiently  emptied,  it  then  becomes  reducible  and  its  return  to 
the  abdominal  cavity  is  announced  by  a  gurgling  or  a  marked  sense 
of  yielding. 

When  the  bowel  is  reduced,  the  omentum,  if  present,  should  be 
returned  in  the  same  manner.  One  should  not  persist  if  the  mass 
is  thick  and  adherent  for  there  is  risk  of  rupture  of  an  omental  vessel, 
which  may  be  followed  by  hemorrhage,  all  the  more  grave  because 
unperceived. 

After  the  hernia  is  reduced  the  patient  must  be  put  to  bed  and 
no  food  by  mouth  permitted  for  at  least  twenty-four  hours.  Before 
getting  about,  a  truss  must  be  fitted. 

If  after  ten  or  fifteen  minutes  of  gentle  effort  the  hernial  tumor 
remains  unchanged  in  size  and  hardness,  it  is  a  waste  of  time  to 
prolong  the  procedure.      It  cannot  be  said  too  often  that  repeated  at- 


532 


STRANGULATED   HERNIA. 


tempts  are  injurious,  becoming  with  each  repetition  more  and  more 
harmful  and  illusory. 

It  may  happen  that  after  the  hernia  has  been  apparently  reduced 
the  symptoms  of  obstruction  still  persist,  or  even  if  at  first  relieved, 
appear  again.  The  tympanites  augments,  the  nausea  and  vomiting 
continue,  and  the  signs  of  sepsis  progress.  It  is  evident  that  something 
is  amiss.  One  of  several  things  may  have  happened,  but  no  time  is  to 
be  wasted  in  conjecture,  for  only  the  operation  which  must  follow  will 
definitely  clear  up  the  doubt. 


Fig.  387. — Strangulated  hernia  reduced 
"  en  masse."      (Moullin.) 


Fig.  388. — Incomplete  reduc- 
tion of  strangulated  loop.  Hernia 
in  a  diverticulum.      (Moullin.) 


It  may  be  that  the  hernial  tumor  has  been  reduced  en  masse. 
The  hernial  sac  and  its  contents  have  been  carried  through  the  ex- 
ternal ring  without  having  changed  their  relations  and  the  constriction 
persists  (Fig.  387).  This  can  occur  in  recent  hernia  in  which  the  sac 
is  not  adherent  and  is  most  common  in  the  direct  form  of  inguinal 
hernia. 

It  may  be  that  instead  of  entering  the  peritoneal  cavity  the  herniated 
loop  has  entered  a  diverticulum  of  the  sac  near  the  neck  and  there 
becomes  once  more  strangulated  (Fig.  388). 

It  may  be  that  the  neck  of  the  sac  has  torn  loose  from  the  rest  of 
the  sac  and  has  been  reduced  with  the  gut,  the  strangulation  still 
being  maintained  (Fig.  389). 


OPERATION    FOR    STRANGULATED    [NGUINA1     III  KMA. 


533 


Again,  a  rent  may  be  torn  in  the  sa<  and  the  gul  escaping  therefrom 
pushes  up  between  the  peritoneum  and  the  abdominal  wall  (Fig.  300)  • 

Finally  the  reduction  may  have  been  complete,  bul  the  gut  was 
gangrenous  or  ruptured  and  a  general  peritonitis  follows,  due  to  the 
escape  of  the  intestinal  contents; 
or  the  peritonitis  may  even  be 
due    to   the   infection  from  the 
septic  fluids  in  the  sac. 

Femoral  and  Umbilical  Her- 
nia.— These  forms  of  strangu- 
lated hernia  require  the  same 
modes  of  procedure  as  the  in- 
guinal but  are  likely  to  present 
more  obstacles.  In  the  case  of 
femoral  hernia,  if  complete,  the 
pressure  must  be  made  down- 
ward toward  the  saphenous 
opening  at  first,  and  then  up- 
ward along  the  femoral  canal. 

In  the  case  of  umbilical  hernia 
the  pressure  must  be  made 
toward  the  umbilical  ring. 
Often  the  Trendelenburg  posi- 
tion is  helpful.  The  constant 
effort  is  first  to  empty  the  gut 
and  then  reduce  it. 

In  both  these  forms  of  hernia 
the  gut  may  be  enveloped  by  a 

mass  of  omentum  which  may  not  be  reducible  and  thus  gives  rise  to 
some  doubt  whether  the  gut  has  been  reduced. 

Operation  for  Strangulated  Hernia:  Inguinal  Hernia. — To  re- 
peat, as  soon  as  a  hernia  habitually  reducible  becomes  painful  and 
irreducible  and  is  accompanied  by  the  signs  of  beginning  prostration, 
regard  it  as  strangulated,  and,  aside  from  the  exceptional  cases  in- 
dicated, operate  at  once.  Do  not  wait  for  fecal  vomiting  for  that  is 
the  last  signal  of  exhausted  nature — the  precursor  of  death. 


Fig.  389. — Strangulated  hernia  reduced 
"en  masse.'  A.  Upper  end  of  the  loop.  B. 
Neck  of  the  sac  torn  off  and  reduced  with  the 
bowel.  C.  Reduced  loop  still  strangulated. 
D.  Scrotal  portion  of  sac.     (Lejars.) 


534 


STRANGULATED    HERNIA. 


General  anesthesia  is  usually  necessary,  although  in  some  cases  of 
profound  sepsis  local  anesthesia  with  cocaine  or  stovaine  suffices, 
using  Schleich's  formula  and  injecting  the  various  layers  just  before 
dividing.     No  special  instruments  are  necessary. 

Surgical  Anatomy. — The  special  points  to  be  remembered  are  the 
situation  of  the  abdominal  rings,  the  relations  of  the  external  and 
internal  oblique  and  transversalis  muscles  to  the  inguinal  canal,  and 
the  location  of  the  deep  epigastric  artery. 

The  external  ring  in  the  aponeurosis  of  the  external  oblique  lies 
just  above  the  spine  of  the  pubes.  The  internal  ring  in  the  trans- 
versalis fascia  lies  a  half-inch  above 
the  middle  of  Poupart's  ligament. 
The  deep  epigastric  artery  passing 
vertically  between  the  two  rings  lies 
between  the  transversalis  fascia  and 
the  peritoneum. 

The    chief    condition   of   operating 
well  is  to  see  and  recognize  what  is  to 
be  divided.      The  coverings  enumer- 
ated with  such  care  by  the  text-books 
will  not  be  distinguished,  but  there  is 
little  danger  of  cutting  into  the  intes- 
tine, for  before  it  can  be  reached  the 
sac  must  be  opened,  and  that  is  an- 
nounced by  the  escape  of  a  character- 
istic sero-sanguinous  fluid.     The  greatest  injury  to  the  bowel  is  at  the 
site  of  constriction,  which  may  be  at  the  external  ring,  the  internal 
ring,  or  the  neck  of  the  sac. 

The  preparation  of  the  field  of  operation  must  be  painstaking. 
The  pelvis  must  be  shaved  and  scrubbed;  the  adjacent  abdominal  and 
inguinal  regions  and  the  scrotum  must  be  thoroughly  disinfected; 
and  the  penis  after  cleansing  wrapped  in  a  sterile  compress. 

First  Step.  Incision.  Exposure  of  the  Sac. — Begin  with  a  skin  in- 
cision extending  from  the  internal  ring  down  to  the  spine  of  the  pubes; 
if  it  is  a  scrotal  hernia,  down  to  the  middle  third  of  the  scrotum  (Fig. 
391).     Go  directly  through  the  skin  and  layers  of  fat  to  the  aponeurosis 


Fig.  390. — Imperfect  reduction  by 
taxis.  Hernia  outside  the  ruptured 
sac.     (Moullin.) 


EXPOSING    THE    SAC    OF   A    STRANCULATKD    IlKRMA. 


535 


of  the  external  oblique,  dividing  the  branches  of  the  superficial  epi- 
gastric artery. 

Expose  the  aponeurosis  thoroughly  and  incise  it  from  one  ring 
to  the  other.  It  is  easily  recognized  by  the  oblique  direction  of  its 
fibers  and  its  shiny  look.  The  lips  of  this  wound  should  be  caught  up 
with  forceps,  especially  at  the  external  ring,  to  serve  later  as  a  land- 
mark in  beginning  repair. 


Fig.  391. — Strangulated  inguinal  hernia;  primary  incision. 


Once  the  aponeurosis  is  opened  the  sac  is  exposed  and  the  next 
effort  is  to  isolate  it  preparatory  to  its  incision.  Separate  it  from 
the  aponeurosis  by  careful  blunt  dissection  around  its  whole  circum- 
ference. Isolate  the  tumor  up  to  the  internal  ring.  If  the  sac  is  too 
intimately  adherent  to  the  aponeurosis  it  may  be  opened  first. 

Second  Step.  Opening  the  Sac. — Catch  a  fold  of  the  sac  with  dissect- 
ing forceps  and  cautiously  divide  the  base  of  this  fold  with  scissors  or 
scalpel  (Fig.  392).     It  may  be  one  of  the  connective  tissue  coverings 


536  STRANGULATED   HERNIA. 

that  is  opened;  divide  it  the  full  length  of  the  wound  and  so  proceed 
until  finally  the  hernial  sac  itself  is  opened,  which  will  be  announced 
by  a  gush  of  bloody  serum.  Cautiously  enlarge  the  opening  till  a 
finger  can  be  introduced,  and  on  it  as  a  guide,  split  the  sac  close  up  to 
its  neck  (Fig.  393).  When  the  constricting  band  is  reached  slip  the 
finger  under  it,  if  possible,  and  divide  it  completely.  If  too  tight  for 
the  finger,  pass  a  grooved  director  as  a  guide.  In  some  cases  it  may 
be  better  to  use  a  herniotomy  knife,  but  wherever  possible  avoid  cut- 


^^t^A> 


Fig.  392. — Opening  the  sac^of  a  strangulated  hernia.     As  soon  as  the  sac  is 
opened  a  sero-sanguinous  fluid  escapes.      (Guibe.) 


ting  blindly.  The  constriction  must  be  freely  divided  so  that  the 
intestine  can  be  readily  drawn  down  for  inspection.  This  step  is  not 
complete  till  that  is  possible. 

It  may  happen  that  there  is  a  second  constricting  band  higher  up; 
in  such  a  case  the  forceps,  which  should  always  be  attached  to  the 
lips  of  the  incision  in  the  sac,  are  useful  in  pulling  it  down  so  that 
what  is  to  be  divided  can  be  seen. 

Third  Step.  Examination  of  the  Intestine. — It  is  of  the  greatest  im- 
portance that  the  site  of  the  constriction  be  examined,  for  the  chief 
lesions  will  be  found  there.  Pull  the  gut  down  and  observe  the  line 
of  demarcation  between  the  healthy  and  injured  tissue  (Fig.  394). 


TRl.ATUI  \  I     "I      I  III      STH  Wi.l   I   VII   I'     I  OOP. 


537 


One  of  several  conditions  will  be  presenl  and  tlu-  line  of  procedure 
will  depend  upon  the  one  which  is  found. 

i.  The  intestine  is  sound;  that  is  to  say,  it  has  a  uniform,  dark 
violet  color,  most  marked  at  the  site  of  the  constriction  where  it 
is  lustrous.     There  is  no  erosion  of  the  serous  covering.     Douching 


Fn"..  393. ■  —  Dividing  the  constricting  fibers  of  the  strangulated  inguinal 
hernia.     The  1 'arts  should  lie  well  exposed,      (fiuibe.) 


the  bowel  with  warm  normal  salt  solution  restores  its  tonicity,  its 
rounded  outline,  and  after  a  few  minutes  it  assumes  a  redder  color  and 
is  to  be  returned  to  the  abdominal  cavity. 

2.  The  intestine  is  slightly  injured;  that  is  to  say,  there  may  be 
several  small  zones  of  erosion  exposing  the  muscular  or  even  the  mucous 
layer.  Bury  these  areas  with  a  few  Lembert  sutures,  repair  any 
injuries  to  the  mesentery,  and  reduce.     If  the  intestinal  loop  is  long. 


538 


STRANGULATED   HERNIA. 


a  methodical  procedure  may  be  required  to  prevent  further  injury 
to  tissues  already  compromised.  The  posterior  segment  of  the  loop; 
should  be  reduced  first,  as  it  probably  was  the  last  to  come  down; 
in  the  meantime  the  anterior  segment  must  be  carefully  supported. 
The  least  rudeness  may  result  in  a  tear. 

3.   The  intestine  is  doubtful;  that  is  to  say,  it  has  a  color  mottled1 


Fig.  394. — Examination  of  the  strangulated  loop.     (Veau.) 


and  gray  and  purple.  It  does  not  recover  its  form  under  the  douch- 
ing, but  stays  collapsed  and  flattened.  Under  these  conditions  it  may 
not  be  possible  to  say  whether  it  is  gangrenous  or  not,  but  it  should 
not  be  reduced. 

Treves,  however,  advises  reduction  under  these  circumstances, 
remarking  (Operative  Surgery,  p.  534,  Vol.  II)  that  whatever  theoret- 
ical objections  to  this  procedure  may  exist,  practice  has  shown 
that  it  may  be  safely  carried  out,  assuming  that  this  applies  to  a 


I  ki  \  I  \n  NT   i»i    QANGR]  NOUS    I  OOP.  539 

towel  which  is  nol  a<  tually  gangrenous,  but  in  ;i  condition  whii  h  may 
be  termed  "doubtful."     It  is  remarkable  to  whal  extent  these  doubt 
ful  intestines  recover.    The  idea  is  that  the  peritoneal  cavity  is  the 
most  favorable  site  for  re<  overy. 

1 1  tin.'  operator  is  inexperienced  and  not  certain  that  he  can  dis- 
tinguish between  the  bowel,  possibly  gangrenous,  and  that  which  has 
actually  lust  its  viability,  he  must  wait.  Wrap  the  loop  in  moist  gauze, 
and  after  tw  elve  hours  examine  again.  It  may  be  gangrenous  or  it  may 
he  viable,  lustrous,  reddened,  rounded,  and  impels  the  belief  that  it  will 
beeome  normal.  With  that  belief,  reduce  it  slowly  and  carefully, 
breaking  up  the  slight  adhesions  which  have  already  formed. 

4.  The  intestine  is  obviously  gangrenous;  that  is  to  say,  the  serous 
coat  has  lost  its  luster,  is  blistered  in  spots,  and  can  easily  be  stripped 
off  with  the  lingers;  its  color  is  ashen  or  even  black,  sometimes  mottled 
with  white  patches;  there  is  a  characteristic  odor;  the  tissues  are 
friable;  and  there  may  be  perforations. 

In  this  case  there  is  but  one  of  two  things  to  do:  either  anchor  the 
gut  in  the  wound  and  make  an  artificial  anus,  or  resect  the  bowel. 

There  can  be  no  doubt  that  an  enterectomy  is  the  ideal  procedure 
since  it  eliminates  a  source  of  danger  and  permits  the  radical  cure 
of  the  hernia,  but  it  is  best  not  to  undertake  it  unless  skilled  in  intes- 
tinal suture  (which  for  that  matter  every  doctor  should  know  thor- 
oughly how  to  do)  for  the  time  required  may  aggravate  the  shock 
and  insure  a  fatality;  but  the  first  consideration  is  to  save  life.  (See 
Enterectomy.)  Allison,  of  Omaha  (Jour.  Minn.  State  Med.  Assn., 
Jan.,  1908),  takes  a  different  view:  "We  believe  primary  end-to-end 
anastomosis  unjustifiable  for,  though  we  escape  shock  and  peritonitis, 
there  yet  remains  the  danger  of  permanent  obstruction  due  to  circu- 
latory and  septic  changes,  or  a  fatal  paralysis  due  to  distention  and 
toxemia.  Artificial  anus  offers  the  best  way  out.  The  two-stage 
operation  is  safer  than  the  primary." 

If  an  artificial  anus  is  considered  safest,  pull  enough  of  the  gut  out 
to  reach  sound  tissue.  Pass  a  catgut  suture  through  the  abdominal 
wall — that  is,  through  the  aponeurosis  and  the  parietal  peritoneum — 
and  then  through  the  superficial  coats  of  the  bowel,  then  out  through 
the  abdominal  wall  again  to  make  the  letter  "U."      Employ  four  such 


540  STRANGULATED   HERNIA. 

sutures  at  the  cardinal  points.  To  the  gangrenous  loop  apply  a  moist 
antiseptic  dressing,  changed  hourly  if  the  intestine  was  perforated.  I 
If  the  intestine  was  not  perforated,  do  not  open  it  at  once,  but  wait  a 
few  hours  till  adhesions  form. 

It  is  then  to  be  opened  and  the  dressings  must  be  frequently  changed, 
for  the  discharge  will  be  abundant.  Later  the  fistula  may  gradually 
close  of  its  own  accord,  more  and  more  of  the  bowel  contents  passing 
by  the  rectum;  or  to  cure  the  fistula  a  difficult  operation  may  be 
necessary.     (See  Temporary  Artificial  Anus.) 

Fourth  Step.  Ligation  and  Amputation  of  the  Sac. — In  every  case 
where  the  bowel  may  be  returned  to  the  peritoneal  cavity,  the  treatment 
of  the  sac  is  of  the  greatest  importance.  After  the  intestine  and  omen- 
tum have  been  reduced  proceed  to  dissect  the  sac,  if  this  has  not  already 
been  done,  remembering  that  the  structures  of  the  cord  may  be  very 
intimately  connected  with  it  and  hard  to  separate.  The  separating  of 
the  cord  from  the  sac  is  often  facilitated  by  stripping  with  the  finger 
wrapped  with  gauze.  When  the  sac  is  completely  isolated  the  neck 
is  to  be  freed  quite  into  the  abdominal  cavity,  and  then  a  finger  is  to 
be  passed  into  the  opening  that  any  omental  adhesions  may  be  de- 
tected or  any  concealed  hemorrhage.  Next,  the  sac  is  to  be  twisted 
and  then  ligated,  or  simply  ligated  as  high  up  as  possible,  and 
amputated. 

In  freeing  the  neck  at  the  internal  ring  the  subperitoneal  fat  is 
usually  seen;  at  this  stage  the  bladder  may  be  injured,  and  the  point 
is  that  any  fatty  tissues  at  the  inner  side  of  the  ring  must  not  be  in- 
cluded in  the  ligature,  for  this  fat  may  conceal  the  bladder. 

In  ligating  the  sac  it  is  best  to  transfix  it  rather  than  use  the  circular 
ligature.  If  the  sac  has  been  split  so  high  that  the  neck  cannot  be 
defined,  then  the  upper  end  of  the  peritoneal  wound  should  be  repaired 
with  a  few  stitches  so  as  to  reconstruct  the  neck  and  then  ligate. 

Fifth  Step. — This  will  depend  upon  the  condition  of  the  patient.  If 
his  condition  is  serious,  it  is  sufficient  rapidly  to  reunite  the  aponeuro- 
sis and  repair  the  skin  incision.  If  a  little  more  time  may  be  used, 
proceed  to  do  the  radical  cure.  Unless  this  is  done  recurrence  is  al- 
most certain,  but  the  operator  cannot  be  held  responsible  for  that. 
In  the  urgent  cases  it  is  sufficient  to  have  saved  a  life. 


M  ii  R   iki  \r\ii  m    I RNIOTOMY.  54  ■ 

Whether  the  radica]  operation  is  attempted  or  not,  employ  drainage. 

rhe  dressing  must  be  carefully  applied. 

Subsequent  Treatment.— The  patient  must  have  no  food  for  24  hours. 
It  may  be  oe<  essary  to  employ  salt  salution  freely.  A  Uttle  ice  may  be 
ten  to  quench  the  thirst.  At  the  end  of  24  hours  begin  with  small 
Lantities  of  milk.  Change  the  dressings  the  second  day  or  sooner  .1 
nuu  h  soiled.  Remove  the  drain  on  the  fifth.  On  the  third  or  fourth 
Ey  give  a  laxative.  Remove  the  sutures  on  the  eighth  or  ninth. 
Peritonitis  may  supervene  if  the  gangrenous  areas  have  not  been 
properly  treated. 

POSSIBLE   COMPLICATIONS   IN   THE   OPERATION. 

In  the  operation  just  described,  the  ordinary  difficulties  are  indicated. 
But  there  are  others,  rarer,  which  may  arise  to  disconcert  the  casual 
operator  not  forewarned.  The  actual  operation  is  always  easier  if 
one  has  in  mind  all  the  possibilities.  There  may  be  unexpected  ad- 
hesions; there  may  be  anomalies  with  respect  to  the  sac  or  its  con- 
tents, or  there  may  be  unsuspected  conditions  produced  by  attempts 

at  taxis. 

Adhesions  must  be  anticipated  when  the  hernia  is  large  and  has 
been  for  a  long  time  irreducible,  and  under  these  circumstances 
special  precautions  must  be  taken  not  to  wound  the  bowel  in  opening 
the  sac.  The  adhesions  if  recent  and  soft  may  be  broken  up  with 
the  finger  or  grooved  director  keeping  in  close  contact  with  the  sac  so 
as  to  avoid  the  bowel. 

If  the  adhesions  are  old  and  the  union  between  the  bowel  or  omen- 
tum with  the  sac  firm  and  fibrous,  it  will  be  necessary  to  divide  them 
with  scalpel  or  scissors,  but  this  is  a  .procedure  requiring  patience 
and  a  delicate  touch.  If  necessary,  long,  band-like  adhesions  may  be 
divided  between  forceps  and  subsequently  ligated. 

If,  following  the  decortication,  the  raw  surfaces  ooze  to  any  serious 
extent,  apply  hot,  moist  compresses  for  a  moment,  and  either  this 
will  check  the  bleeding  or  at  least  reveal  the  site  of  the  larger  vessels 
to  be  caught  up  with  forceps.  Usually  a  few  applications  of  the  hot 
compresses  will  entirely  suppress  the  oozing,  or  to  a  degree  at  least 
which  will  not  contraindicate  reduction,  for  when  the  bowel  is  do 


542  STRANGULATED   HERNIA. 

longer  bent  and  the  circulation  no  longer  interfered  with  the  oozing 
will  cease. 

But  it  is  chiefly  injury  to  the  bowel  which  is  to  be  feared,  not  soj 
much  because  the  rent  may  be  difficult  to  repair  as  that  some  of  the' 
septic  contents  of  the  bowel  may  escape. 

If  the  adhesions  cannot  be  broken  up  the  only  thing  left  is  to  remove 
the  source  of  the  strangulation  and  leave  the  bowel  outside.  Occa- 
sionally it  will  be  found  that  the  source  of  strangulation  is  in  some 
of  the  adhesions  rather  than  the  rings,  or  the  neck  of  the  sac;  or,  again, 
so  much  scar  tissue  in  the  bowel  wall  leaves  it  inert  and  paralyzed.  All 
these  difficulties  are  more  likely  to  occur  in  the  neglected  cases. 

A  hernia  of  the  cecum  or  sigmoid  may  present  difficulties  depend- 
ing upon  adhesions.  It  must  be  remembered  that  these  two  portions 
of  the  large  intestine  are  not  completely  invested  by  peritoneum ;  and,  in 
consequence,  it  may  come  to  pass  that  when  they  slide  down  through 
the  inguinal  canal  a  point  is  reached  where  a  part  of  the  bowel  is  out- 
side the  hernial  sac,  and  this  surface  acquires  adhesions  to  the  scrota] 
tissues.  In  such  cases  these  adhesions  cannot  be  divided  for  fear' 
of  wounding  important  branches  of  the  mesenteric  arteries,  so  that 
to  effect  reduction  a  special  procedure  must  be  employed. 

In  the  first  place,  when,  on  opening  the  hernial  sac,  these  parts 
of  the  large  bowel  are  recognized,  the  neck  of  the  hernia  must  be  freely 
incised  and  the  abdominal  walls  as  well.  In  fact,  one  does  what  Lejars 
calls  a  hernio-laparotomy . 

Next  the  hernial  sac  is  separated  from  the  spermatic  cord  and 
then  an  effort  is  made  to  reduce  the  hernia  en  masse,  returning,  if 
possible,  the  bowel  and  the  peritoneal  prolongation  at  the  same  time. 
It  will  be  a  slow  and  tedious  process.  It  is  greatly  aided  by  the  Tren- 
delenburg position.  If  the  attempt  fails,  an  artificial  anus  is  the 
last  resort. 

Among  the  anomalies  of  the  sac  which  may  bother  the  operator 
are  diverticula  and  double  compartments.  One  may  open  into  what 
appears  to  be  the  hernial  sac  and  find  it  empty.  In  encysted  hernia 
the  processus  vaginalis  may  be  filled  with  fluid  which  surrounds  the 
true  hernial  sac.  A  little  study  of  the  conditions  will  lead  one  to  go 
ahead  and  find  and  open  the  true  hernial  sac. 


I  I'l    \  I  Ml    \  I      m       \     III    K\l  \  I  1    !>     Ill    U'l'l    R. 

The  hernial  sac  may  push  in  between  the  peritoneum  and  the 
muscular  layers,  bulging  toward  the  iliac  fossa  or  the  bladder.  This  is 
thf  pro  peritoneal  hernia,  and  when  ii  becomes  strangulated  it  is  not 

likely  a  diagnosis  will  be  made.  Yet  the  presence  of  B  tumor  in  the 
inguinal  region  and  the  signs  of  intestinal  obstruction  will  demand  an 
operation  and  again  a  hernio  laparotomy  is  indicated.  The  site  of 
strangulation  is  located  and  the  bowel  treated  as  in  the  ordinary  form 
of  strangulated  hernia. 

In  the  interstitial  form  of  hernia  great  difficulties  may  arise.  The 
incision  is  likely  to  he  quite  different  from  the  ordinary  since  it  follows 
the  long  axis  of  the  tumor.  Once  die  hernial  sac  is  exposed  it  must 
be  freed  from  its  adhesions  to  the  muscles.  The  neck  of  the  sac 
corresponds  to  the  internal  ring,  and  if  that  is  the  site  of  constriction  it 
must  he  divided  by  cutting  outward.  The  deep  epigastric  artery  lies  to 
the  inner  side. 

After  the  bowel  is  reduced  and  the  sac  ligated,  the  break  in  the 
abdominal  wall  must  be  sutured,  repairing  the  opening  in  each  layer 
separately. 

The  contents  of  the  hernial  sac  may  be  abnormal.  At  some  time 
or  other  each  of  the  abdominal  organs  except  the  pancreas  have  been 
found  herniated.  It  is  the  bladder  which  most  often  gives  rise  to 
trouble. 

It  may  be  in  the  sac  and  appear  as  a  second  "sac"  when  the  hernial 
sac  is  opened.  It  presents  as  a  rounded,  reddish  tumor,  perhaps  as 
large  as  a  hen's  egg.  Such  a  tumor  should  never  be  opened  on  sus- 
picion, but  a  careful  effort  must  be  made  to  locate  its  limits  by  blunt  dis- 
section. The  fact  that  it  leads  down  to,  and  behind,  the  pubes  clears 
up  any  doubt.  It  is  to  be  reduced  in  the  same  manner  as  the  intestine. 
In  other  instances  it  is  without  the  sac,  lying  to  the  inner  side  of  its 
neck  and  is  perhaps  intimately  connected  thereto.  It  may  be  mistaken 
for  a  thickened  portion  of  the  sac  or  an  adherent  mass  of  fatty  tissue. 

If  it  is  opened  into,  the  escape  of  urine  and  the  evidence  to  the  e\ 
■mining  finger  of  a  large  mucus  lined  cavity  reveals  the  nature  of  the 
accident  and  imposes  immediate  repair. 

A  large  hernia,  easily  reducible,  or  one  whose  size  diminishes,  follow- 
ing urination  or  the  use  of  the  catheter  suggests  hernia  of  the  bladder; 


544  STRANGULATED   HERNIA. 

but,  unfortunately,  these  signs  are  not  available  in  strangulation.  In 
every  herniotomy  the  danger  of  wounding  the  bladder  must  be  kept  in 
mind. 

Another  point  Lejars  makes:  One  may  expose  a  thin-walled  trans- 
parent cyst  at  the  inner  side  of  the  neck  of  the  sac,  and  unwittingly 
open  it  only  to  find  oneself  working  into  the  bladder.  This  trans- 
parent cyst,  in  nowise  resembling  the  bladder,  is  due  to  a  hernia  of  the 
mucosa  of  the  bladder  between  the  fibers  of  the  muscularis. 

Following  the  separation  of  the  bladder  from  the  hernial  sac  the 
urine  may  be  bloody  for  a  day  or  two.  This  hematuria  is  of  little 
moment  and  soon  clears  up. 

If  the  bladder  is  wounded  its  repair  must  precede  everything  else. 
As  soon  as  the  injury  is  discovered,  pack  around  the  site  with  sterile 
gauze,  catch  the  edges  of  the  wound  with  small  forceps  and  suture, 
uniting  the  mucosa  first  with  a  continuous  cat-gut  suture,  and  the 
muscular  coat  with  interrupted  sutures,  accurately  applied;  a  third 
line  connects  the  superficial  tissues. 

The  appendix  may  be  found  in  the  hernial  sac,  either  inflamed  or 
normal.  If  the  latter,  it  is  to  be  removed  in  the  ordinary  way  unless 
time  presses,  in  which  case  one  must  be  satisfied  with  reducing  it. 

If  the  symptoms  of  strangulation  arise  in  consequence  of  an  in- 
flamed and  herniated  appendix,  they  may  differ  somewhat  from  those 
ordinarily  observed.  There  will  be  the  same  tendency  to  collapse,  the 
vomiting,  the  tympanites;  but  constipation  may  not  be  complete,  and 
the  hernial  tumor,  in  addition  to  being  swollen  and  painful,  may  be 
reddened  and  edematous. 

No  one  should  think  of  taxis  under  these  circumstances:  an  im- 
mediate operation  is  indicated.  Regarding  these  grave  cases,  Kelly 
says  (Vermiform  Appendix  and  its  Diseases,  p.  793)  where  there  is 
suppuration  in  the  sac  it  must  be  drained,  and  here  as  well  as  in  the 
cases  where  there  is  gangrene  in  the  appendix,  resulting  from  strangu- 
lation, the  utmost  care  must  be  observed  in  handling  the  diseased 
tissues  in  order  to  avoid  inoculating  the  peritoneal  cavity.  If  the  dis- 
eased portion  is  found  to  extend  up  into  the  peritoneal  cavity,  the 
operator  must  at  all  hazards  discover  the  upper  limits  of  the  infection 
and  resect  the  bowel  in  its  healthy  portion. 


iki  \i\ii  \i    01    \    in  RNIAT1  D   APPENDIX.  545 

Moreover,  he  must  « 1 « >  this  with  the  hast  possible  manipulation 
ami  tra<  t  it  *  r  i  upon  the  parts,  preferably  by  enlarging  the  abdominal 
Opening  in  the  direction  of  the  inguinal  canal  while  protecting  the 
healths-  regions  and  keeping  the  disease  well  isolated  by  abundant 
jgauze  compresses. 

When  infection  extends  still  further  up  into  the  abdomen  an  even 
wider  incision  must  be  made,  if  necessary,  in  the  form  of  an  inverted 
,|,  in  order  to  provide  abundant  drainage  after  removal  of  the  disease. 
In  such  cases  the  cure  of  the  hernia  becomes  a  matter  of  secondary  con- 
sideration to  he  taken  up  after  recovery. 

McEwen  (London  Lancet,  June  16,  1906)  reports  a  case  in  which 
the  patient,  a  man  of  62,  presented  himself  for  an  operation  for  strangu- 
lated hernia.  Two  weeks  previously  his  hernia  (of  12  years'  standing) 
had  begun  to  give  him  pain,  which  had  gradually  increased. 

A  large  pyriform  tumor  occupied  the  right  inguinal  region  and 
the  scrotum,  which  was  much  inflamed.  The  mass  was  dull  on  per- 
cussion, there  was  no  impulse  on  coughing,  and  it  was  irreducible. 
On  opening  the  sac  the  hernia  was  found  to  consist  of  the  appendix, 
held  in  position  by  a  pin  protruding  through  its  wall.  There  was  no 
abscess  formation,  yet  it  was  not  deemed  advisable  after  removal  of 
the  appendix  to  proceed  with  the  radical  cure. 

Regarding  these  unusual  conditions,  Lejars  remarks  that  in  be- 
ginning an  operation  for  strangulated  hernia  we  should  expect  every- 
thing and  be  surprised  at  nothing;  laying  aside  for  the  moment  all 
theoretical  discussions  and  applying  ourselves  to  the  chief  indication, 
not  deeming  our  work  complete  until  the  bowel  is  properly  reduced 
and  lost  to  view  in  the  abdominal  cavity. 

Oliver,  of  Indianapolis  (Ind.  Med.  Jour.,  March,  1908),  reports  a 
case  in  which  the  hernia  had  grown  to  remarkable  proportions  extend- 
ing as  low  as  the  knee.  The  mass  had  long  been  irreducible.  The 
patient  was  a  butcher  of  about  50  years  of  age.  Following  a  heavy 
meal  of  "pigs'  feet"  and  a  lift,  his  hernia  suddenly  became  painful 
and  he  experienced  the  sensation  of  something  giving  way;  symptoms 
of  strangulation  in  mild  form  gradually  developed;  taxis  being  out  of 
the  question,  immediate  operation  was  practised.  On  opening  the 
hernial  sac  it  developed  that  its  content  was  the  stomach  in  its  entirety, 
35 


546  STRANGULATED   HERNIA. 

but  no  gut  was  present.  With  great  difficulty  it  was  reduced.  The  pa- 
tient's condition  did  not  permit  of  any  further  manipulation,  and  shortly 
afterward  he  succumbed.  Oliver  expresses  the  opinion  that  the 
stomach  had  been  forced  down  into  the  sac  by  the  strain,  replacing  the 
gut. 

Femoral  Hernia.— Operation  is  even  more  urgent  in  the  case  of 
strangulated  femoral  hernia  than  in  strangulated  inguinal  hernia. 
Gangrene  is  likely  to  develop  earlier,  and  taxis  is  all  the  more  ineffectual 
by  reason  of  the  anatomical  arrangement.  Especially  must  one  be 
on  his  guard  in  the  case  of  small  hernia,  for  then  the  femoral  ring  is 
small  and  unyielding.  It  is  essential  to  have  the  anatomy  in  mind  to 
understand  this  and  especially  to  operate  without  embarrassment. 

Surgical  Anatomy. — Poupart's  ligament  stretches  across  the  front  of 
the  pelvic  region  from  the  anterior  superior  spine  of  the  ilium  to  the 
spine  of  the  os  pubis.  The  space  between  this  band  and  the  ramus 
of  the  pubis  is  occupied  by  several  structures — from  without  inward, 
the  iliacus  and  psoas  muscles  on  their  way  to  the  lesser  trochanter,  the 
crural  nerve,  the  femoral  artery  and  vein,  the  femoral  canal,  and  Gim- 
bernat's  ligament. 

Gimbernat's  ligament  is  a  firm  triangular  fascia  with  its  base 
directed  outward  and  abutting  the  femoral  canal. 

The  femoral  sheath,  a  prolongation  of  the  iliac  fascia,  encloses 
the  femoral  vessels.     In  the  thigh  it  fits  closely  about  the  vessels. 

In  the  groin  the  sheath  is  more  capacious  so  that  there  is  a  space 
left  between  its  inner  wall  and  the  femoral  vein.  This  space  constitutes 
the  femoral  canal.  The  femoral  canal  is,  therefore,  conical  in  shape 
with  its  base  above  and  its  apex  below  where  the  sheath  gets  in  contact 
with  the  femoral  vein.  The  circumference  of  the  base  constitutes  the 
femoral  ring  which  is  bounded  internally  by  the  base  of  Gimbernat's 
ligament;  above,  by  Poupart's  ligament;  below,  by  the  ramus  of  the 
pubes;  externally,  by  the  femoral  vein.  The  narrow  orifice  bounded 
by  these  structures  is  the  usual  site  of  strangulation  of  a  hernia  de- 
scending along  this  slender  channel. 

It  is  Gimbernat's  ligament  whose  sharp  edge  is  most  likely  to 
shut  off  the  circulation  of  a  loop  of  intestine  bulging  past  it  and  which 
is  most  likely  to  cut  into  or  bruise  the  bowel  in  efforts  at  taxis  (Fig.  395). 


OPERATION    FOR    STRANGULATED    HUM'U     III  KM. \. 


5  17 


In  other  cases  the  hernia  descending  lower  finds  the  direction 
id"  least  resistance  toward  the  surface  and  bulges  out  through  the 
saphenous  opening  and  the  <  ribriform  fascia. 

Operation,     [f  the  operation   is  done  early  before  complications, 


Pig.  395.     Relations  i  i  the  neck  of  a  femoral  hernia  under  Poupart's 
ligament.     {Moullin.) 


such  as  gangrene,  have  arisen,  the  operation  for  strangulated  femoral 
hernia  is  simple  and  without  special  danger.  Begin  by  disinfecting 
the  whole  held;  the  inner  surface  of  the  thigh,  the  groin,  the  abdomen, 
the  genitals. 

The  incision   may   be  vertical,   following  the  axis  of  the  tumor,  or 


548  STRANGULATED   HERNIA. 

oblique,  below  and  parallel  to  Poupart's  ligament;  Lejars  prefers  the 
latter,  claiming  that  it  gives  freer  access  to  the  femoral  ring,  facilitates 
the  dissection  of  the  sac  and  the  procedures  in  the  radical  cure. 

The  vertical  incision  is  probably  better  for  large  and  lobulated 
hernia  which  extend  well  below  Poupart's  ligament.  But  whatever, 
incision  is  employed  must  be  of  ample  length. 

The  incision  traverses  the  skin,  and  then  a  fatty  layer  through 
which  ramify  a  number  of  veins  tributary  to  the  long  saphenous. 
Having  divided  this  layer,  the  sac  is  exposed;  or,  at  least,  the  fatty  en- 
velope in  which  so  often  it  is  enclosed — a  collection  of  fat  which  at  times 
amounts  to  a  veritable  lipoma.  The  hernial  sac  lies  immediately  be- 
neath this  fat — sometimes  in  thin  subjects  immediately  beneath  the. 
skin — and  presents  itself  in  divers  aspects.  Usually  it  looks  like  a 
tense  and  reddish  cyst;  often  it  is  lobulated. 

Second  Step. — Isolate  the  sac.  Proceed  to  separate  it  from  the  ad- 
jacent tissues  by  blunt  dissection,  peeling  it  out  with  the  fingers 
and  disengaging  it  quite  up  to  the  neck.  It  is  essential  for  the  later 
steps  of  the  operation  that  this  be  thoroughly  done  and  is  complete 
when  Poupart's  and  Gimbernat's  ligaments  are  well  in  view. 

This  dissection  of  the  sac  takes  less  time  than  one  might  expect 
and  is  greatly  facilitated  if  one  is  able  to  find  a  line  of  cleavage  be 
tween  the  tissues.  Sometimes  bursa?  intervene  between  the  sac 
and  adjacent  tissues  and  favor  a  rapid  separation. 

Third  Step. — Open  the  sac;  examine  the  contents.  Once  the  hernia] 
tumor  is  well  exposed  up  to  the  constricting  ring,  cautiously  incise 
the  sac.  Caution  is  required  because  often  it  is  difficult  to  know 
when  one  has  penetrated  the  sac  and  an  adherent  intestine  may 
be  wounded.  In  this  form  of  hernia  the  true  sac  may  be  covered  by!  I 
a  cyst,  which  may  be  filled  by  bloody  serum  and  thus  simulate  the 
appearances  of  the  hernial  sac.  A  moment's  examination,  however, 
shows  that  it  is  a  small  closed  cavity  without  communication  with  the! 
abdomen.  The  layers  are  to  be  cautiously  divided  one  by  one  unti. 
the  sac  is  opened  into  and  the  opening  enlarged. 

Catch  up  the  lips  of  the  wound  of  the  sac  and  examine  its  contents 
Usually,  in  this  form  of  strangulated  hernia,  one  will  see  a  small  loop 
of  intestine,  darkened,  tense,  and  tightly  constricted.     Occasional!) 


STRANG1  LATED    I  \ir.n  [CA1   Hi  RNIA.  S  \<> 

llong  with  the  omentum  there  may  be  several  loops  of  small  intestine,  or 
he  <  e<  win,  or  the  sigmoid  flexure,  [rrigate  the  <  avity  and  its  i  ontents 
,viih  normal  salt  solution  and  prepare  to  relieve  the  constriction. 

Fourth  Step-  Relieve  the  constriction.  The  first  effort  should  be  to 
relieve  the  strangulation  by  stretching  the  offending  fibers,  t<>  this 
aid  introducing  a  finger,  if  possible,  into  the  ring  along  the  innci  side 
>f  the  hernia. 

( Oftentimes  the  pressure  thus  exerted  will,  with  a  little  effort,  streti  h 
in<l  enlarge  the  opening  sufficiently  to  relieve  the  constriction  and 
i)  permit  the  necessary  manipulation  of  the  bowel. 

It  may  not  be  possible  to  introduce  a  finger,  and  then  one  must 
resort  to  incision.  To  accomplish  this  a  grooved  director  may  be 
slipped  up  alongside  the  bowel  and  the  fibers  divided  with  scissors  or 
bistoury,  or  if  the  fibers  are  in  plain  view,  as  they  should  be,  they  may 
be  nicked  with  the  point  of  the  bistoury  and  when  room  is  thus  made 
the  finger  may  be  introduced  as  before.  The  use  of  the  herniotomy 
knife,  cutting  blindly,  should  be  reserved  for  exceptional  cases,  where 
the  subject  is  fleshy  and  the  obstruction  beyond  reach  and  very  tight. 

But  whatever  method  may  be  practised,  one  must  keep  to  the  in- 
side, cutting  inward  or  upward  to  avoid  injury  to  the  bowel  or  the 
femoral  vein. 

When  the  obstruction  is  removed  pull  the  bowel  down  and  examine 
it.  If  it  is  suspicious  or  gangrenous,  treat  it  after  the  manner  indi- 
cated under  Strangulated  Inguinal  Hernia. 

If  it  is  sound,  reduce  it;  liberate  the  sac  around  the  femoral  ring, 
■gate  and  resect  it;  and  close  in  some  manner  the  femoral  canal. 
(See  operation  for  radical  cure.)  The  after-treatment  is  the  same  as 
for  inguinal  hernia. 

It  remains  to  be  said  that  in  exceptional  cases  it  may  be  necessary, 
in  order  to  see  what  to  do,  to  divide  Poupart's  ligament;  or,  in  the  male 
where  the  cord  is  to  be  avoided,  to  make  another  incision  along  the 
inguinal  canal,  exposing  the  neck  of  the  hernia;  or,  following  the 
method  of  Tuftier,  to  open  directly  into  the  peritoneal  cavity  through 
the  inguinal  canal. 

Strangulated  Umbilical  Hernia. — A  strangulated  umbilical  hernia 
is  pe<  uliar  in  two  or  three  respei  ts.      It  is  likely  to  be  deceptive  in  that 


550  STRANGULATED   HERNIA. 

the  characteristic  symptoms  of  intestinal  obstruction  may  be  wanting. 
The  site  of  strangulation  is  more  likely  to  be  in  the  sac  than  at  the  um- 
bilical ring.  But  because  the  absolute  signs  of  obstruction  are  absent  t 
and  because  the  opening  at  the  umbilicus  seems  patent,  one  has  no 
excuse  to  delay  when  an  old  and  long  irreducible  rupture  becomes 
suddenly  painful,  with  vomiting  and  partial  constipation. 

Too  often,  as  Lejars  says,  we  call  these  attacks  with  comparatively 
mild  onset,  pseudo-strangulation;  and  so  the  case  drifts  along  while 
septic  absorption  goes  on  insidiously  but  surely.  From  day  to  day 
the  circulation  grows  weaker,  the  abdomen  more  tympanitic,  the 
vomiting  more  pronounced,  until  the  vital  forces  are  practically  over- 
come, at  which  time,  too  late,  it  is  decided  to  operate.  The  expectant 
treatment  and  repeated  taxis  in  these  cases  are  merely  methods  of 
"losing  time." 

Following  such  practice  one  can  confidently  expect  a  large  per- ' 
centage  of  fatalities,  though  one  should  not  hesitate  to  operate  even 
in  the  face  of  such  odds.     Operating  early  one  may  give  assurance  of 
excellent  results.     To  quote  Lejars  again,  it  is  not  the  operation  which  i 
is  to  be  feared:  it  is  the  delay. 

Operation. — Careful  disinfection  of  the  whole  abdominal  wall;  a 
prudent  and  cautious  anesthesia.  The  incision  may  follow  the  median 
line  extending  well  beyond  the  tumor  above  and  below;  or  in  the  case 
of  a  large  tumor,  may  consist  of  two  semilunar  incisions  on  either  side 
of  the  middle  line  which  enables  one  to  get  rid  of  redundant  tissue. 

In  either  case  the  incision  must  not  go  deep  from  the  first  for  often 
the  skin  is  quite  thin,  often  adherent  to  the  sac,  and  it  is  easy  to  go1 
directly  into  the  sac.  By  reason  of  this  adhesion  at  the  center  of  the| 
tumor,  begin  the  dissection  at  the  poles  of  the  incision  and  work  toward; 
the  center. 

As  soon  as  the  skin  is  detached  proceed  to  isolate  the  tumor,  if 
possible,  up  to  its  point  of  emergence.  It  may  not  be  practicable 
if  the  tumor  is  large  and  lobulated  to  take  the  time,  and  in  such  a  case 
the  sac  may  be  opened  into  at  once. 

Second  Step. — Open  the  sac.  Detach  the  omentum.  Nearly  always 
on  first  opening  the  sac  only  omentum  can  be  seen.  It  completely 
envelops  the  bowel.     The  fingers  are  gently  insinuated  between  the 

I 


OPERATION    FOB    STRANG1  LATED    I  Ml.ilK   \l     111  RNIA.  551 

Omentum  ami  the  sac,  and  the  adhesions  progressively  broken  down. 
I  Wherever  a  lobule  of  omentum  is  found  encysted  in  a  diverticulum 

of  the  sac  it  must  be  dissected  oul  in  the  same  manner.     Finally  the 

entire  omentum  will  he  freed,  may  be  lilted  up,  and    the   gut   exposed 

pFig.  396). 

irrigate  both  the  bowel  and  omentum  with  normal  salt  solution, 
wipe  with  sterile  gauze  and  examine  the  bowel  carefully  to  see  that  there 
is  no  danger  of  perforation  and  of  soiling  of  the  peritoneum  in  the 
process  of  reduction. 

Third  Step. — Relieve  the  str angulation .  Oftentimes  the  umbilical 
ring  may  need  only  to  be  stretched  a  little  to  permit  the  free  manip- 
ulation of  the  bowel;  again,  it  may  be  necessary  to  divide  the  con- 
stricting fibers.  This  may  be  most  readily  accomplished  by  pulling 
down  the  omentum,  slipping  a  finger  between  it  and  the  upper  part  of 
the  ring  to  the  left  of  the  middle  line.  If  this  nick  does  not  give  suffi- 
cient release,  repeat  on  the  opposite  side. 

When  the  necessary  room  is  obtained,  ligate  the  omentum,  resect 
it,  cleanse  the  stump  and  reduce  it  that  there  may  be  nothing  to  inter- 
fere with  the  treatment  of  the  bowel. 

With  respect  to  the  bowel,  the  same  principle  of  treatment  holds 
good  as  in  inguinal  hernia.  Repair  any  slight  defects  or  abrasions. 
If  its  viability  is  doubtful,  keep  it  under  observation  for  a  few  hours. 
If  gangrenous,  either  anchor  it  in  the  wound  and  make  an  artificial 
anus  or  do  an  enterectomy. 

It  may  be  that  in  very  large  umbilical  hernia  it  is  better  to  modify 
the  procedure,  following  the  plan  of  Mayo  and  others,  in  order  to 
gain  time. 

A  transverse  elliptical  incision  is  made  around  the  tumor  at  such 
distance  from  the  center  that  the  redundant  tissue  shall  be  removed. 
Cut  down  to  the  sac.  Next  cautiously  open  the  sac  following  the  skin 
incision.  Apply  several  forceps  to  the  edges  of  the  sac  so  that  it  is 
constantly  under  control.  Detach  the  omentum,  freeing  it  completely 
up  to  the  neck  of  the  sac.  Ligate  and  resect  it,  and  working  along  its 
under  surface  free  it  from  the  bowel.  Once  detached  the  paquet  of 
omentum  carries  with  it  a  segment  of  the  skin  and  of  the  sac. 

The  bowel  IS  next  treated  and  reduced.      This  mav  not  be  as  easily 


552 


STRANGULATED   HERNIA. 


done  as  said  for  there  are  several  circumstances  under  which  the 
bowel  may  push  out  and  threaten  eventration.     But  no  effort  should  be 
made  to  push  back  the  rebellious  loops  en  masse. 
Proceed  at  once  to  enlarge  the  opening,  lift  up  the  edges  of  the 


Fig.  396. — Umbilical  hernia:  dissection  of  sac.     {Mayo.) 


peritoneum  by  the  attached  forceps  and  cover  the  bowel  with  a  wide 
compress,  tucking  its  edges  under  the  belly  walls  on  all  sides,  as  de 
scribed  elsewhere.     As  little  by  little  the  bowel  is  returned  the  edges  of 
the  compress  are  slipped  farther  under.     When  reduction  is  complete 
the  compress  is  left  in  situ  until  the  sutures  are  placed. 

Fourth  Step. — The   mode   of  repairing  the  abdominal  wall  varies 


Kl  I'MK    "I      I  III      \|:|M.\l|\.\l      U.M.I. 


with  the  circumstan<  es  and  the  operator,  and  depends  upon  how  much 
time  <>nc   may  dare  take.     When  the  condition  of   the  patient  im 
poses  great  baste  ii  must  suffice  to  pass  interrupted  sutures  through 
the  whole  thi<  kness  of  the  belly  wall  and  draw  the  edges  of  the  wound 


Ph 


-Umbilical  hernia;  repair  of  abdominal  wall.     {Mayo.) 


together  SO  that  the  peritoneal  edges  point  out  and  the  two  serous 
surfaces  are  thus  brought  into  contact.  Before  the  last  suture  is  tied 
the  compress  is  removed;  and  finally  a  continuous  suture  will  com- 
plete the  reunion. 


554  STRANGULATED   HERNIA. 

If  more  time  is  available,  after  the  sac  is  trimmed  its  edges  are 
sutured  as  after  a  laparotomy.  The  sheaths  of  the  recti  muscles 
are  opened  up  and  the  inner  border  of  each  muscle  exposed.  The  two 
sides  are  then  brought  in  contact  and  three  tiers  of  sutures  applied; 
one  uniting  the  deep  layer  to  its  fellow  of  the  opposite  side;  the  second 
uniting  the  two  muscles;  the  third  uniting  the  two  superficial  layers  of 
the  sheath. 

Finally  the  excess  of  subcutaneous  fat  is  trimmed  away  and  the 
skin  sutured.  The  usual  dressing  is  used,  held  in  place  by  a  wide 
binder,  and  the  after-treatment,  already  indicated,  is  instituted. 

Figs.  396  and  397  show  the  manner  in  which  Mayo  perfects  the 
radical  cure. 

Obturator  Hernia. — A  strangulated  obturator  hernia  is  rare,  yet  it  is 
to  be  thought  of  and  ruled  out  before  opening  the  abdomen  for  in- 
testinal obstruction.  Several  points  help  to  locate  the  trouble  even 
when  no  marked  tumor  is  present.  The  presence  of  pain  over  the 
region  of  the  obturator  foramen  directs  the  attention  to  that  point,  and 
pressure  made  there  projects  a  pain  down  the  inner  side  of  the  thigh 
to  the  knee,  along  the  course  of  the  obturator  nerve.  In  the  female 
vaginal  examination  will  reveal  the  tumor. 

In  this  form  of  strangulated  hernia,  taxis  is  useless  and  likely  to  be 
very  harmful,  and  therefore  must  never  be  employed.  A  herniotomy 
must  be  done  without  delay,  though  in  these  cases  it  is  a  procedure 
by  no  means  simple.  Several  anatomical  points  must  be  borne  in 
mind.  The  hernia  usually  comes  out  through  the  upper  part  of  the 
obturator  membrane  and  is  covered  over  by  the  pectineus  muscle. 
It  may  work  into  the  pectineus  or  it  may  lie  on  a  lower  level,  working 
into  the  obturator  externus.  The  pectineus  is  usually  the  chief  guide 
to  the  hernia. 

The  obturator  vessels  and  nerve  are  usually  found  behind  and 
to  the  outer  side  of  the  neck  of  the  hernia,  though  one  cannot  count  on 
that.  The  femoral  vessels  lie  to  the  outer  side.  It  is  the  obturator 
membrane  which  constitutes  the  constricting  ring. 

The  operation,  chiefly  as  described  by  Treves,  is  as  follows:  The 
pelvis  is  elevated,  the  thigh  flexed  and  adducted,  the  femoral  artery 
located,  and  about  a  finger's  breadth  internal  an  incision  is  made  from 


STRANG!  I  Ml  D    0BT1   RATOH    III  KM  A. 


555 


the  spine  of  tin*  pubes  downward  for  three  or  f<>ur  inches,  [ncise  the 
skin,  the  subcutaneous  fal  and  the  fascia  lata,  and  expose  the  addut  tor 
longus.  Catch  up  the  deep  external  pudic  artery.  Retract  the 
adductor  brevis  and  beneath  thi>  is  the  pectineus  whose  fibers  are 
separated  by  blunt  dissection;  or,  if  necessary,  divided  in  order  to 

expose  the  sac  1 I' i.L,'.  308). 


PlG.    .;'<*. — Obturator   hernia.      A.    Hernial  sac-obturator  artery.      B.   Pectineus. 
C.  Adductor  longus.     (Lejars.) 


\\  hen  the  sac  is  once  in  view,  free  it  completely  up  to  the  neck. 
The  obturator  membrane  is  now  to  be  nicked,  observing  first  the 
course  of  the  arteries.  It  is  better,  however,  to  open  the  sac  at  once, 
cleanse  the  contents,  and  endeavor  to  insinuate  the  finger  alongside 
the  bowel  and  stretch  the  Strangulating  fibers;  failing  in  this,  to  divide 
them,  keeping  in  mind  the  possibility  of  a  hemorrhage.      If,  in  spite  oi 


556  STRANGULATED   HERNIA. 

precaution,  this  occurs,  tampon  firmly  against  the  obturator  mem- 
brane, and  when  the  tampons  are  removed  one  by  one,  the  bleeding 
points  may  be  recognized  and  clamped.  Finally  the  intestine,  if 
sound,  is  reduced,  the  sac  dissected  and  ligated  high  up,  and  the  ex- 
ternal wound  sutured. 

Lejars  remarks  that  one  may  find  in  the  sac  of  a  strangulated 
obturator  hernia  not  only  bowel  and  omentum,  but  also  the  tubes  and 
ovaries,  the  bladder  and  the  appendix;  and  that  it  is  well  to  be  fore- 
warned of  these  possibilities,  which  may  greatly  complicate  an  opera- 
tion at  best  never  simple. 

Of  strangulation  of  other  forms  of  hernia— sciatic,  lumbar,  perineal, 
vaginal — it  need  only  be  said  that  they  are  too  rare  to  be  with  profit 
considered  here. 


CHAPTER  XII. 


RADICAL  CURE  OF  INGUINAL  HERNIA. 


(JO  PO  T  Ft  p 


The  radical  cure  of  hernia  may  be  attempted  at  the  operation  for 
strangulated  hernia  under  the  conditions  defined.  Hut  aside  from 
those  emergency  cases  there  arc  others  in  which  the  family  doctor 
will  feel  it  his  duty  to  recommend  and  to  do  the  operation,  ilis 
results  will  be  excellent  if  he  wisely  chooses 
cases  not  beyond  his  skill.  As  Veau  says,  he 
should  select  only  such  as  arc  small,  reducible, 
congenital.  The  large  hernias  are  difficult  to 
handle  and  recurrence  will  be  almost  certain. 
The  irreducible  hernias  may  have  acquired  ad- 
hesions that  can  scarcely  be  broken  up  without 
severe  injury  to  the  gut.  With  respect  to  age, 
the  ideal  case  is  a  young  man  fifteen  to  twenty- 
five  years  old,  who  has  well-developed  ab- 
dominal walls,  a  well-defined  external  abdom- 
inal ring,  and  a  hernia  easily  controlled  by  a 
truss. 

Under  these  favorable  conditions,  the  hernia 
rarely  recurs;  but  almost  certainly  it  will  recur 
if  suppuration  follows  the  operation,  and  there- 
fore absolute  asepsis  is  the  sine  qua  non  of 
success. 

Surgical  Anatomy. — The  hernia,  then, 
which  the  general  practitioner  should  under- 
take to  operate  on  is  an  external  or  oblique,  which  escapes  from  the 
abdominal  cavity  through  the  internal  ring  to  the  outside  of  the  deep 
epigastric  artery  and  follows  the  inguinal  canal  down  to  the  externa] 
ring  (Fig.  399). 

Beneath  the  skin  will  be  found  only  a  few  insignificant  vessels. 

The   aponeurosis   of   the   external    oblique    is   easily   distinguished. 
Strong   ami   resistant,   and   its   fibers   bounding   the  external   ring   are 

557 


Fig.  399. — Transverse 
vertical  section  of  the  in- 
guinal canal  showing  rela- 
tion of  the  hernial  sac. 
GO,  external  oblique;  PO, 
internal  oblique;  T,  trans- 
versalis;  Ft,  transversals 
fascia;  /',  [uritoneum;  TC, 
conjoined  tendon ;  I 
cremaster; .  d,  vas  deferens 
in  contact  with  the  hernial 
sac  represented  in  black. 
(\\-a:>.) 


558 


RADICAL    CURE    OF   INGUINAL   HERNIA. 


thickened  to  form  the  "pillars"  of  the  ring.  Behind  it  lies  the  cord, 
which  includes  the  vas  deferens  and  its  accompanying  vessels  and 
nerves,  all  surrounded  by  a  common  sheath  derived  from  the  trans- 
versalis  fascia,  and  in  this  case,  it  contains  also  the  hernial  sac.  To 
reach  the  sac,  the  sheath  must  be  divided  and  the  elements  of  the  cord 
separated  from  the  sac. 

In  the  case  of  congenital  inguinal  hernia,  the  sac  is  very  thin  and, 
in  spite  of  precautions,  it  is  sometimes  torn  01  one  even  fails  to  find  it. 


Fig.  400. — The  primary  incision  for  hernia.      (Veau.) 


The  chief  difficulty  of  the  operation  centers  around  the  recognition 
and  dissection  of  the  sac.  The  posterior  wall  of  the  inguinal  canal 
is  formed  by  the  conjoined  tendon,  the  transversalis  fascia,  and  the 
peritoneum. 

The  purpose  of  the  operation  is  to  reconstruct  the  posterior  wall 
and  restore  the  obliquity  of  the  canal,  and  the  "Bassini"  operation  is 
the  type  the  inexperienced  operator  can  best  imitate. 

Operation. — Prepare  the  field  most  scrupulously — abdomen,  thigh, 
and  scrotum.  Employ  general  anesthesia,  as  a  rule,  although  local 
and  spinal  anesthesia  are  available. 


|\i  IM<>\     FOR    IM.l   l\  \l.    Ill  KM  \. 


Begin  bj  locating  the  external  ring,  which  is  to  l>c  the  first  point  of 
attai  k. 

'/'/.'<•  incision  will  extend  from  this  orifice  to  a  poinl  just  over  the  in 
lernaJ  ring,  which  lies  one-half  inch  above  the  middle  of  Poupart's  liga- 
ment.    The  incision,  then,  beginning  above  (on  the  right)  (Fig.  400), 
extends  downward  and   forward  to  the  spine  of  the  pubes,  where  it 
bends  a   little  to  become  more  vertical  and  ends  in  the  l>asc  of  the 


PlG.  401. — The  external  oblique  exposed  aivl  the  external  ring  developed.      {Veau.) 


scrotum.  However  large  the  hernia  may  he,  one  need  not  extend 
the  incision  further,  so  lax  and  distensible  are  the  scrotal  tissues. 

Having  divided  the  skin  and  subcutaneous  tissues,  catch  up  and 
Kate  the  small  vessels.  Next  divide  the  fatty  tissues  layers  by  layer 
down  to  the  aponeurosis  of  the  external  oblique,  which  lies  deeper 
than  one  may  expect. 

Now,  with  the  grooved  dire,  tor,  completely  expose  the  pillars  of  the 
ring.  Do  not  neglect  this  as  it  is  a  most  important  step  in  the  oper- 
ation. The  inner  pillar  is  easily  found,  but  the  outer  pillar  is  covered 
by  the  cord  and  a  little  patience  is  required  to  get  it   well  exposed. 


56o 


RADICAL   CURE    OF   INGUINAL   HERNIA. 


Catch  up  each  pillar  with  forceps;  these  are  not  to  be  loosened  until, 
at  the  end  of  the  operation,  they  have  served  as  a  guide  in  the  repair 
of  the  external  ring  (Fig.  401). 

Now  comes  the  next  step  in  the  operation^  Carefully  divide  the 
aponeurosis  in  the  line  of  the  pillars  and  to  the  full  extent  of  the  skini 
wound.  Unless  one  cuts  deeply,  there  is  nothing  to  fear.  You  have; 
now  laid  open  the  inguinal  canal  and  have  left  to  do  the  most  difficult 
part  of  the  operation. 


Fig.   402. — The    external  oblique  divided,  exposing  the  cord  and  hernial  sac.      (Veau.) 


To  Find  and  to  Dissect  Out  the  Sac. — The  cord  is  covered  by  the  cre- 
master  which  also  covers  the  hernial  sac.  You  may  begin  the  search; 
for  the  hernial  sac  without  disturbing  the  position  of  the  cord,  but  it  is! 
better  to  raise  it  up  out  of  its  bed.  To  do  this  follow  along  the  external 
pillar  and  Poupart's  ligament  and  you  will  find  it  easily  disengaged ! 
by  blunt  dissection  (Fig.  402).  Slip  the  left  index  finger  under  and 
support  the  cord.     The  sac  is  enclosed  in  the  fibrous  sheath  of  the  cord. 

Very  gently  incise  this  sheath,  using  a  sharp  bistoury  (Fig.  403),  and, 
the  structures  of  the  cord  appear.  Rolling  them  between  the  finger 
and  thumb,  you  can  recognize  the  vas  deferens  by  its  form  and  con- 
sistency. You  can  see  the  distended  veins.  You  will  see  a  whitish 
transparent  membrane.  Catch  up  a  fold  of  it  with  the  forceps  and 
divide  its  base,  and  if  it  is  the  sac,  you  will  open  into  a  serous  cavity 
(Fig.  404).     Enlarge  the  orifice  sufficiently  to  introduce  a  finger  and, 


EXPOSING     I  III     III  KM  \l     SAC 


56l 


Fig.  403. — Dividing  the  fibrous  coverings  of  the  sac.      (I  eau.) 


Pio.  404.     Incising  tlu-  hernial  sac.     il  tan  1 


36 


562 


RADICAL   CURE    OF    INGUINAL   HERNIA. 


with  that  as  a  guide,  dissect  the  sac  from  its  associated  structures 
(Fig.  405).  It  is  often  a  difficult  task,  for  the  veins  and  vas  deferens 
are  glued  to  the  sac,  especially  in  the  congenital  hernia.  Sometimes 
pressing  and  stripping  the  tissues  back  with  a  gauze  compress  facilitates ] 
the  manoeuvre. 

It  is  important  that  the  sac  be  isolated  quite  to  the  internal  ring 
(Fig.  406) ;  otherwise  when  the  ligature  is  applied  there  will  be  formed 


Fig.  405. 


-The  index  finger  introduced  into  the  sac  which  is  being  separated 
from  the  other„structures  of  the  cord.      {Guibe.) 


a  peritoneal  diverticulum,  the  starting-point  later  of  another  hernia. 
Do  not  carry  the  dissection  further  than  the  internal  ring  for  fear  of 
wounding  the  bladder. 

Assure  yourself  now  that  the  sac  is  empty  by  passing  a  finger  up 
into  the  abdominal  cavity.  Now  transfix  the  neck  of  the  sac  with  a 
needle  carrying  a  catgut  ligature  (Fig.  407)  and  tie  in  the  manner  in- 
dicated in  figure  (Fig.  408).  If  the  ligature  merely  encircles  the 
neck,  it  is  too  likely  to  slip  off.     Do  not  cut  off  the  ends  of  the  ligature 


I>|n>i  i   ||\(.    \\|>    i|i.  VTING     I  Hi     SAC. 


563 


Pig.  400.    -The  sew  separated  from  the  cord;  the  cord  in  the  bottom  <>f  the  wound, 

on  either  side  the  lips  of  the  external  oblique. "^_(  Vain.) 


»  8l  1 1 

Pio.  107.     Ligation  "f  the  neck  of  the  >vu\     (l 


564 


RADICAL    CURE    OF    INGUINAL   HERNIA. 


until  through  dealing  with  the  sack.  Amputate  the  sac  within  one-half 
inch  of  the  ligature  and,  if  everything  is  all  right,  cut  the  threads  and 
the  stump  disappears  in  the  cavity.  Sellenings  proposes  to  dispense 
with  the  dissection  of  the  sac.  After  it  is  exposed,  incised,  and  emp- 
tied, he  obliterates  it  by  passing  a  purse  string  around  its  neck  at  the 
internal  ring  and  suturing  the  rest  of  its  length  (Amer.  Jour.  Surgery, 
March,  1909). 

Suture  of  the  Abdominal  Walls. — This  is  the  next  step.     Draw  the 
cord  down  out  of  the  way  for  the  moment  and  expose  the  shelving 


Fig.  408. — Illustrating  method  of 
ligating  the  sac.      (Veau.) 


Fig.  409. — The  cord  drawn  to  one  side  while  the 
posterior  wall  of  the  canal  is  restored  by  suture 
of  the  conjoined  tendon  to  the  shelving  edge  of 
Poupart's  ligament.      (Veau.) 


inner  edge  of  Poupart's  ligament,  which  is  to  be  sutured  to  the  free 
border  of  the  conjoined  tendon.  In  other  words,  the  internal  oblique 
and  transversalis  are  to  be  sutured  jointly  to  Poupart's  ligament. 

Through  this  shelving  edge  near  the  pubis  pass  a  chromic  catgut 
suture  on  a  curved  needle  and  carry  it  through  the  corresponding  part 
of  the  conjoined  tendon  (Fig.  409),  and  apply  three  or  four  such 
sutures  (Fig.  410).  In  this  manner  reconstruct  the  posterior  wall  of 
the  inguinal  canal.  Place  the  cord  back  in  position  upon  this  line  of 
sutures. 

Now  draw  the  edges  of  the  divided  aponeurosis  into  position  by 
means  of  the  forceps  attached  to  the  pillars  at  the  beginning  of  the 
operation.  Begin  the  repair  by  a  chromic  catgut  suture  at  the  upper 
end  of  the  wound  (Fig.  411)  and  pass  six  or  eight  in  this  manner. 


i    i  i   ri      \\i.    i .  i  ■  i  SSING    01    mi     WOUND. 


565 


The  last  will  rejoin  the  pillars  and  restore  the  external  ring,  and 
when  these  are  all  tied  the  anterior  wall  of  the  (anal  is  thus  recon 
Btructed.     There  is  little  danger  of  making  the  external  ring  too  small 
for  the  cord  (Fig.  1 12). 

Complete  the  hemostasis.  A  scrotal  hematoma  may  develop  unless 
one  is  very  particular  about  the  oozing. 

Complete  the  operation  by  suture  of  the  skin  wound  with  silkworm- 
gut,  leaving  in  it  a  small  drainage-tube  if  you  fear  infection  or  oozing; 
otherwise  this  is  not  necessary;  still  it  does  no  harm. 

Cover  the  wound  with  a  strip  of  moist  gauze,  fix  it  with  collodion, 
and  then  apply  the  ordinary  gauze  and  cotton  dressing.  A  double 
spica  bandage  will  greatly  diminish 
the  chance  of  infection.  If  drainage 
was  employed,  remove  the  tube  in 
two  or  three  days  under  strictest 
asepsis.  Otherwise  do  not  disturb 
the  dressing,  but  watch  the  tempera- 
ture. If  the  temperature  runs  up  to 
j oi°  on  the  third  day,  open  up  the 
wmi  nd  by  removing  one  or  two  sutures, 
and  if  there  is  any  pus,  drain. 

Delay  in  this  is  likely  to  result  in  ex- 
tensive suppuration,  and  a  recurrence  of  the  hernia  is  thus  assured. 
If  everything  goes  well,  remove  the  stitches  on  the  eighth  day,  but 
keep  the  patient  in  bed  for  three  weeks.     A  truss  is  not  necessary. 

Rilus  Eastman,  of  Indianapolis,  recommends  a  modification  of  the 
final  suturing  especially  applicable  in  the  case  of  children.  His  method 
aims  at  the  closure  of  all  the  layers  by  a  single  tier  of  easily  removable 
non-buried  sutures.  The  method  described  (Annals  of  Surgery, 
Jan.,  1906)  consists  in  the  reduction  of  the  sac  by  the  ordinary  proced- 
ure. A  I'agenstecher  celloidin  linen  suture  bearing  a  needle  on  each 
end  is  then  first  passed  through  Poupart's  ligament  from  without  in- 
ward one  inch  from  its  free  margin.  It  is  next  passed  through  the 
outer  border  of  the  obliquus  exlernus  and  transversalis  muscles  and 
brought  back  through  I'oupart's  ligament  about  1/3  inch  nearer  the 
margin  than  at  its  first  point  of  passage.      The  needle  now  external  to. 


Fir, 


410. — Posterior  wall-repair 
complete.     (Veau.) 


566 


RADICAL    CURE    OF   INGUINAL   HERNIA. 


and  above  Poupart's  ligament  is  made  to  overlap  the  free  margin  of 
the  ligament  and  the  aponeurosis  of  the  external  oblique  by  carrying 
the  thread  through  in  the  form  of  a  simple  running  mattress  suture. 


Fig.  411. 


-Reconstructing  the  anterior  wall  by  repair  of  the  external  oblique.  Forceps 
still  attached  indicate  the  position  of  the  ring       (Veau.) 


The  needle  is  next  passed  through  the  superficial  fascia,  panniculus 
adiposus,  and  skin,  emerging  about  1/8  inch  from  the  skin  wound 
margin  upon  the  side  opposite  Poupart's  ligament.     When  traction  is 


Fig.  412. — External  oblique  repaired.     (Veau.) 

made  upon  the  two  ends  of  the  suture  no  kinks  or  curls  remain,  and  the 
suture  is  tied  up  as  a  simple  loop.  Five  or  six  such  sutures  are  re- 
quired to  coapt  the  wound  from  the  internal  ring  to  the  pubes.  When 
union  is  complete  they  are  easily  clipped  and  removed. 


CHAPTER  XIII. 
RADICAL  CURE  OF  FEMORAL  HERNIA. 

Aside  from  the  cases  of  strangulated  hernia,  the  general  practitioner 

should  not  undertake  the  operation  for  the  radical  cure  of  femoral 
hernia  without  due  consideration  and  without  warning  the  patient  that 
relapse  is  possible  and  even  frequent.  The  operation  is  not  more 
difficult  than  that  for  inguinal  hernia,  but  a  cure  is  much  less  certain. 
As  with  inguinal  hernia,  he  should  select  only  such  cases  as  are  small 
and  reducible. 

Surgical  Anatomy. — The  sac  of  a  femoral  hernia  is  generally  thick 
and  imbedded  in  adipose  tissue  originating  in  the  extra-peritoneal 
layer.     (See  Strangulated  Femoral  Hernia.) 

The  relations  at  the  neck  are  of  the  greatest  importance.  To  the 
outside  is  the  femoral  vein  in  direct  contact,  easily  perforated  by  a  care- 
less needle  and  producing  a  hemorrhage  that  can  be  arrested  only  by 
ligature  of  the  vein.  To  the  inside  is  Gimbernat's  ligament,  sharp- 
edged  and  tense,  the  chief  structure  to  be  dealt  with  in  strangulation. 
Above  is  Poupart's  ligament,  separating  the  femoral  from  the  inguinal 
canal,  and  below  is  the  ramus  of  the  pubes,  thinly  covered  by  the 
pectineus  and  its  fascia.  These  boundaries  are  unaccommodating 
structures  in  the  matter  of  repair,  and  for  this  reason  relapse  is 
frequent. 

Operation. — The  anesthesia  and  preparation  are  the  same  as  for 
inguinal  hernia. 

The  incision,  parallel  with,  and  a  finger's  breadth  below  Poupart's 
ligament,  begins  (on  the  left  side)  at  the  spine  of  the  pubis  and  is 
usually  about  four  inches  in  length  (Fig.  413). 

Incise  in  the  same  manner  the  fatty  tissues,  layer  by  layer,  until  the 
easily  distinguishable  coverings  of  the  hernia  are  reached.  The  line 
af  cleavage  between  them  and  the  fatty  tissues  is  followed  and  the 
aeck,  lying  high  and  deep,  is  exposed.     Where  the  coverings  seem 

567 


568 


RADICAL    CURE    OF   FEMORAL   HERNIA. 


thinnest,  catch  up  a  fold  with  the  dissecting  forceps  and  incise  the 
base.  It  may  be  that  the  incision  will  only  open  into  another  fatty 
layer.  Divide  the  next  layer  in  the  same  manner,  and  so  proceed  until 
you  have  opened  the  sac;  secure  its  edges  with  forceps  and  pass  an 
index  finger  into  the  cavity.  If  omentum  is  found  it  must  be  resected 
(pig.  414).     Be  sure  there  is  no  adherent  bowel. 

•  Now  dissect  the  sac,  proceeding  slowly  and  methodically  until  the 
femoral  ring  is  reached.     Introduce  a  finger  to  be  sure  the  bowel  is 


Fig.  413. — Incision  for  femoral  hernia.      (Veau.) 


protected,  and  transfix  and  ligate  the  neck  of  the  sac  as  in  inguinal 
hernia.     Again  recall  the  relations  of  the  femoral  ring  (Fig.  415). 

Obliteration  of  the  Femoral  Ring. — Retract  the  upper  angle  of  the 
wound  so  that  you  can  see,  and  with  the  edge  of  the  bistoury  held] 
horizontally,  divide  Gimbernat's  ligament  freely  (Fig.  416).  Poupart's 
ligament  can  now  be  approximated  to  the  pectineus.  Protect  the; 
femoral  vein  with  a  retractor  and  pass  the  first  suture  adjoining  it, 
using  a  strong  curved  needle  and  No.  2  or  No.  3  catgut. 

The  needle  enters  the  pectineal  fascia,  grazes  the  bone,  comes  out  a 
little  higher,  and  then  passes  up  to  the  posterior  surface  of  the  liga- 


<   [.OS!    K'l      "I      I  III      II   \1<  iK  A I      RING. 


569 


mi-lit  and  forward  through  it  (Fig.  117).  Place  four  sutures  in  this 
manner  before  tying  (Fig.  |i*).  Tie  them  successively  from  without 
inward.  It  is  this  line  of  suture  alone  that  will  be  effii  ient,  bul  suture 
the  fascia  if  you  wish,  and  finally  the  skin. 

The  subsequent  treatment  is  the  same  as  in  inguinal  hernia. 

Such  is  the  method  which  Watt  recommends,  and  which  has  the 
(great  merit  that  it  is  anatomical.  Bul  there  are  many  differences 
of  opinion  as  to  the  best  method  of  closing  the  femoral  ring,  and  as 
to  the  advisability  of  even  closing  it  at  all. 


PlG.  J14. — Resection  of  the  omentum.     (Guibc.) 


Ochsner  enunciates  the  principle,  applying  it  to  the  radical  cure 
of  femoral  hernia,  that  circular  openings  in  any  part  of  the  body, 
will  certainly  close  unless  kept  open  by  a  mucous  or  serous  lining. 
Wherever,  therefore,  the  femoral  ring  is  well  defined,  he  is  content 
with  high  ligation  of  the  sac  and  dissection  of  all  the  fat  and  simple 
closure  of  the  wound.  With  a  technic  thus  reduced  to  the  simplest 
terms,  he  obtains  excellent  results.  Unfortunately,  the  femoral  ring 
cannot  always  be  defined  as  a  circular  opening,  and  especially  after 
the  operation  for  strangulated  hernia. 

Coley  in  the  main  agrees  with   Ochsner,  but   lays  somewhat   more 


57° 


RADICAL    CURE    OF   FEMORAL   HERNIA. 


stress  on  the  closure  of  the  femoral  canal.     His  method,  described 
briefly  in  Progressive  Medicine  (June,  1907),  is  as  follows: 

An  oblique  incision  is  made  1/4  to  1/2  inch  below  Poupart's  liga- 
ment and  parallel  with  it,  almost  identical  with  incision  made  for  in- 


Fig.  415. — The  neck  of  the  sac 
ligated  and  cut  off.  Above,  Poupart's 
ligament;  below,  the  ramus  of  the 
pubes;  internally,  Gimbernat's  liga- 
ment.     (Veau.) 


Fig.    416. — Femoral    hernia;    incision    of 
Gimbernat's  ligament.      (Veau.) 


Fig.  417. — Suturing  Poupart's  liga- 
ment to  the  pectineal  fascia.      ( Veau.) 


Fig.  418. — Suture  of  Poupart's  ligament  and 
pectineal  fascia  completed.      (Veau.) 


guinal  hernia,  only  slightly  lower  and  a  little  shorter.  The  sac  with  the 
mass  of  extra-peritoneal  fat  that  almost  always  surrounds  it,  is  then 
freed  well  up  into  the  femoral  opening.  The  masses  of  fat  are  care- 
fully removed;  the  sac  itself,  by  gentle  traction,  is  brought  down  well 


CL0S1   RE    01     I  III      II  \K'K Al.    KIN<;. 


57' 


beyond  its  ne<  k  to  a  point  where  it  widens  into  the  general  peritoneal 
cavitv.  It  is  always  opened  before  ligature,  to  make  sure  it  is  empty. 
Il"  omentum  is  present,  this  is  tied  off  and  removed,  the  sac  is  trans 

A 


■'///', 


PlG.  419. — Closure  of  femoral  ring. 
Sutures  passed  through  Poupart's  liga- 
ment and  the  pectineal  fascia.      (Bintlte.) 


FlG.  420. — Suture  of  femoral  ring  com- 
pleted, by  passing  sutures  through  the 
plica  falciformis  and  pectineal  fascia, 
1  Binnie.) 


fixed,  resected,  and  reduced.  With  a  curved  Hagedorn  needle 
threaded  with  kangaroo  tendon  of  medium  size,  the  suture  is  placed, 
passing  the  needle  first  through  the  inner  part  of  Poupart's  ligament, 
then  downward  through  the  fascia  lata  overlying  the  femoral  vein,  and 


Fig.  421. — Roux's  operation  for  closure  of  the  femoral  ring.     {Binnie.) 


finally  upward,  emerging  through  the  roof  of  the  canal  1/4  inch 
distant  from  the  point  of  entrance.  On  tying  this  suture  the  floor  of 
the  canal  is  brought   into   apposition  with  the  roof  and  the  femoral 


572  RADICAL   CURE    OF    FEMORAL  HERNIA. 

opening  is  completely  obliterated.  The  skin  and  superficial  fascia  are 
closed  with  uninterrupted  catgut  suture.  The  first  change  in  dressing 
is  made  in  a  week,  and  the  patient  is  allowed  to  go  home  at  the  end  of 
two  and  a  half  weeks. 

Another  method  is  represented  in  Figs  419  and  420.  In  Roux's 
operation,  Poupart's  ligament  is  brought  down  to  the  pubes  by  a  metal 
or  ivory  steeple  (Fig.  421). 


(  ilAI'TKR   XIV. 
ENTERECTOMY.     INTESTINAL  ANASTOMOSIS. 

Resection  of  a  segment  of  the  small  intestine  may  be  a  necessary 
fart  of  several  emergency  operations.  It  may  be  required  following 
gunshot  or  other  lacerating  wounds  of  the  intestine;  it  may  be  neces- 
sary in  certain  wounds  of  the  mesentery  and  in  the  gangrene  of  strangu- 
lated hernia. 

Large  wounds  of  the  gut,  those  which  carry  away  more  than  one- 
lr.ll'  the  circumference,  require  resection,  for  any  form  of  repair  is  likely 
to  result  in  stricture.  In  the  case  of  multiple  perforations,  it  is  safer  to 
(teect  than  to  attempt  separate  repair  of  the  orifices.  A  small  wound 
of  the  omentum  near  the  intestinal  border  may  require  an  extensive 
resection,  for  an  inch  of  mesentery  at  that  level  may  contain  the  blood 
supply  of  two  feet  of  intestine. 

Resection  of  the  bowel,  implies  anastomosis,  and  this  may  assume 
one  of  three  forms:  it  may  be  end-to-end — termino-terminal,  termino- 
latrral,  or  latero-lateral. 

The  end-to-end  anastomosis  is  preferable  following  resection. 
The  method  employed  may  be  either  by  suturing — circular  enteror- 
rhaphy — or  by  the  Murphy  button  or  some  of  the  other  mechanical 
devices,  such  as  Robson's  bone  bobbin  or  Frank's  decalcified  bone 
coupler.  With  the  great  majority  of  surgeons,  suturing  is  the  method 
of  choice,  although  the  casual  operator  may  not  yet  be  ready  to  dis- 
card the  mechanical  device. 

Moynihan,  in  his  great  work  on  abdominal  operations,  sums  the 
matter  up  in  this  wise:  "The  use  of  mechanical  appliances  is  no  longer 
necessary;  these  have  played  their  part — a  most  important  part.  1 
gratefully  admit  in  the  development  of  surgical  work,  and  it  is  now 
time  thai  their  surgical  use  should  be  abandoned.  They  have  been 
useful,  nay,  indispensable  steps  in  the  march  of  progress.  To  Murphy 
above  all  other  surgeons     for  his  instrument  is  one  oi   the  most  in 

573 


574  ENTERECTOMY.      INTESTINAL  ANASTOMOSIS. 

genious  mechanical  contrivances  ever  invented — we  should  gratefully 
acknowledge  the  debt  we  owe.  The  weightiest  argument  against  all 
mechanical  aids  to  anastomosis  is  this — they  are  unnecessary.  By 
their  aid  we  do  not  accomplish  anything  which  cannot  be  accomplished 
with  equal  rapidity  and  greater  safety  by  simple  suture.  We  have 
nothing  to  gain  from  their  use  and  we  risk  much  by  leaving  something 
behind  which  may  be  and  has  been  the  direct  cause  of  danger  and  of 
death.  The  day  of  mechanical  aids  is  over.  The  buttons  and  the 
bobbins,  the  elastic  ligatures  and  the  forceps  of  many  forms  have  no 
more  than  a  historical  interest." 

Technic  of  Resection. — The  first  essential  of  this  procedure  is 
that  all  the  impaired  gut  be  removed.  Otherwise  subsequent  slough 
and  perforation  are  almost  a  certainty.  There  is  a  limit,  of  course,  to 
the  length  of  the  segment  which  may  be  safely  removed,  but  in  the 
ordinary  operation  one  need  not  fear  to^remove  too  much.  Cases  are 
on  record  in  which  as  much  as  ten  feet  of  the  small  intestine  have  been 
removed  with  recovery.  As  Moynihan  said,  it  is  not  so  much  a  ques- 
tion of  how  much  is  removed  as  how  much  is  left  to  carry  on  the  in- 
testinal functions.  A  second  requisite  in  resection  is  that  the  blood 
supply  of  the  bowel  be  left  unimpaired.  Lack  of  precaution  in  this 
respect  may  nullify  an  otherwise  careful  operation. 

The  integrity  of  a  given  part  of  bowel  is  absolutely  dependent  upon 
the  condition  of  the  vessels  which  arise  from  the  last  arterial  arch 
to  supply  it.  It  must  be  remembered  that  the  vasa  intestini  tenuis 
break  up  into  a  number  of  freely  anastomosing  arches,  but  the  terminal 
branches  anastomose  but  little.  It  is  this  character  of  the  circula- 
tion which  determines  the  mode  of  section  of  the  mesentery. 

The  third  principle  constantly  to  be  borne  in  mind  is  that  the  peri- 
toneum is  to  be  completely  protected  from  contamination  by  the  bowel 
contents.  It  is  true  of  all  the  hollow  viscera  that  their  contents  are 
more  or  less  septic,  always  sufficiently  so  to  produce  peritonitis.  The 
bowel,  then,  must  always  be  temporarily  constricted  beyond  the  limits  of 
the  section.  This  is  ordinarily  done  by  means  of  intestinal  clamps  or 
by  elastic  ligature  or  by  gauze  strips  passed  through  a  button-hole  in 
the  mesentery. 

Not  only  must  the  intestinal  contents  be  restrained,  but  also  the 


RESK<    I  IMS    in      I  III      'I    I  . 


575 


field  of  operation  must  be  shut  <>iT  from  the  peritoneal  cavity  :i m I  from 
jontact  with  the  resl  of  the  viscera  by  means  of  sterile  compr< 

The  larger  and  more  deeply  placed  of  these  are  iml  to  be  removed  Until 

the  i-ii<l  of  the  operation;  the  smaller  and  mure  superficial  should  be 
Banged  from  time  to  time  as  soiled. 

To  resect  a  portion  of  the  intestine,  then,  begin  by  getting  the 


Fii..  422. — Resection  of  the  bowel;  showing  lines  of  incision  of  bowel  and  omentum. 


injured  coil  well  into  view  and  pack  around  it  with  sterile  compresses. 
It  may  be  advisable  as  a  further  security  now  to  put  the  patient  in  the 
Trendelenburg  position.  Strip  the  portion  of  bowel  to  be  removed,  so 
;as  to  empty  it,  and  apply  a  clamp  well  beyond  each  end  of  the  con- 
demned segment.  The  clamps  are  not  placed  directly  across  the 
■bowel,  but  obliquely,  so  that  more  of  the  convex  than  of  the  mesenterit 
border  is  included.  A  portion  of  the  mesentery  is  included  in  the  bite 
of  the  forceps. 


576 


ENTERECTOMY.      INTESTINAL  ANASTOMOSIS. 


The  lines  of  the  section  are  prolonged  into  the  mesentery  so  that 
they  meet  just  short  of  the  nearest  arterial  arch.  It  is  better  to  make 
the  base  of  the  mesenteric  wedge  even  narrower  than  the  mesen- 
teric margin  of  the  intestinal  segment.  There  is  then  scarcely  any 
danger  that  the  circulation  will  be  impaired  (Figs.  422,  423). 

Technic  of  Anastomosis. — (a)  By  suture.     Employ  two  lines  of 


Fig.  423. — Resection  of  bowel;  showing  segment  of  bowel  and  omentum  removed. 


suture.  One  perforates  the  bowel  wall,  brings  the  cut  edges  into  ac- 
curate contact,  and  is  hemostatic;  it  may  be  called  the  " perforating " 
suture.  The  other  passes  only  through  the  serous  and  muscular  coats 
— or  even  better  the  submucous — and  after  the  manner  of  the  Lembert 
suture  brings  the  serous  surfaces  into  contact,  buries  the  perforating 
sutures  and  effectually  prevents  any  of  the  bowel  content  from  reach- 
ing the  peritoneal  cavity.  Most  surgeons  employ  a  straight  needle  ! 
and  silk.     Moynihan  likes  the  curved  needle  and  celluloid  thread. 


END-TO-END    W  VSTOMOSIS. 


577 


To  in  i  rod  me  the  suture  begin  by  placing  the  clamps  side  by  side, 
bringing  the  posterior  surfaces  of  the  bowel  into  contact.  Con 
led  these  two  surfaces  by  .1  continuous  sero  serous  suture,  extending 
worn  the  mesenteric  border  to  the  convex  border  (Fig.  \?\).  Leave 
the  thread  long  where  tied  at  the  point  of  beginning  and  catch  it 
with  forceps.  <  >n  rea<  hing  poinl  "  B  "  leave  the  needle,  still  threaded, 
hut  wrap  it  in  gauze  and  Lay  it  aside  for  the  moment. 

Now  begin  the  perforating  suture  at  the  mesenteric  margin.     The 
two  leaves  of  the   mesentery   separate  here   to  encircle   the   dowels, 


PlG.  434. — End-to-end  anastomosis;  the  first  part  of  the  sero-serous  or  Lembert 
suture  applied.      Beginning  the  inclusive  suture.      (Binnie.) 

leaving  a  part  of  the  surface  bare.     The  stitch  must  be  passed  so  as  to 
bring  the  mesentery  in  contact  with  this  bare  area. 

Proceed  in  this  manner:  Pass  the  needle  through  the  bowel  wall 
[beginning  with  the  right  side)  about  1/6  inch  from  the  cut  edge,  enter 
ing  the  mucus,  emerging  from  the  serous  coat  just  where  the  mesentery 
rcu<  In  s  the  bowel.  Carry  the  needle  over  and  across  to  the  left  side, 
pass  it  through  into  the  lumen,  reversing  the  first  puncture.  Pass  it 
next  from  within  out.  perforating  the  wall  near  the  mesenteric  juncture, 
and  finally  perforate  the  right  bowel  wall  again,  passing  from  without 
inward.  The  knot  is  tied  within  the  lumen  of  the  gut  at  the  original 
point  of  entrance.  The  edges  of  the  mesentery  being  thus  brought 
37 


578  ENTERECTOMY.      INTESTINAL  ANASTOMOSIS. 

together,  the  suture  is  carried  continuously  around  the  whole  circum- 
ference of  the  gut  (Fig.  425).     The  punctures  are  1/10  to  1/12  inch 
apart  and  the  work  is  facilitated  by  keeping  the  thread  taut,  which  at ! 
once  tightens  it  sufficiently  and  brings  into  view  the  site  of  the  next  punc- : 
ture.     The  end  of  the  suture  is  knotted,  the  thread  left  long  at  the 
beginning  and  thus  the  perforating  suture  is  completed.     Remove  the  1 
clamps. 


A 


Fig.  425. — -End-to-end  anastomosis;  the  first  part  of  the  Lembert  suture  buried  by  the 
inclusive  suture  which  will  be  completed  before  resuming  the  Lembert  A  B.      (Binnie.) 

It  remains  to  complete  the  sero-serous  suture  which  was  temporarily 
abandoned.  It  is  carried  from  the  convex  border  on  around  to 
the  mesenteric  border,  and  when  that  point  is  reached  the  perforating 
suture  is  completely  buried.  Knot  with  the  thread  left  long  in  the  be- 
ginning and  held  with  forceps,  and  thus  the  sero-serous  suture  is  com- 
pleted (Fig.  426).  Finally  suture  the  rent  in  the  mesentery.  This 
must  never  be  neglected,  else  it  may  be  the  site  of  a  strangulated 
hernia.  The  line  of  suture  is  to  be  carefully  wiped,  the  compresses  re- 
moved, and  the  loop  returned  to  the  abdominal  cavity. 


\\  OTOBIOSIS    B\    Ml  K  I'l  ( \     i:i   I  l<>\. 


579 


(hi  By  the  Murphy  button  (Fig.  .127).  The  bowel  is  resected  as  de- 
scribed above.  Begin  by  passing  a  purse  string  suture  around  the 
towel  near  its  cut  edge,  involving  all  the  layers.  The  chief  concern  is 
t.>  get  control  of  the  mesentery  whore  its  layers  separate.     To  do  this 

A 


l'n;.  436. — End-to-end  anasto- 
mosis completed.  A  and  B  to  be 
knotted.      (Minnie.) 


A        P  B 

Fig.  427. — Murphy  button. 


Fig.  428. —  Purse- 
striiiK'  suture  (b)  run- 
ning over  edge  of  bowel 
and  closing  space  be- 
tween mesentery  (c)  at 
(a).      (Shwart.) 


Fig.  429. — Anastomosis  with  Murphy  button  completed. 
{limine  after  DaCosta.) 


pass  the  needle  through  one  layer,  on  into  the  lumen  of  the  bowel; 
out  again  through  the  bowel  wall  and  through  the  other  layer  of  mesen- 
tery (Fig.  428). 

When  the  suture  is  puckered  the  intermesenteric  space  is  obliterated. 


58o 


ENTERECTOMY.       INTESTINAL  ANASTOMOSIS. 


Now  grasp  one  half  of  the  button  with  forceps  and  introduce  it  into 
the  end  of  the  gut  so  that  when  the  purse-string  suture  is  tightened 
it  will  fall  into  the  groove  in  the  button. 

Adjust  the  other  half  of  the  button  in  the  same  manner.     The 
male  half  is  pressed  firmly  into  the  female  half,  noting  that  all  the 


Fig.  430. — Lateral  anastomosis  facili- 
tated by  use  of  clamps.  Continuous  su- 
ture for  both  layers.      (Binnie.) 


Fig     431. — Lateral    anastomosis;    first 
row  of  Lembert  sutures  applied.   (Binnie.) 


edges  are  turned  in.  Strengthen  the  union  by  a  few  Lembert  sutures. 
Repair  the  rent  in  the  mesentery  and  the  anastomosis  is  complete 
(Fig.  429).  It  may  be  expected  that  the  button  will  pass  about  the 
tenth  day. 

Lateral  Anastomosis. — Proceed  as  before,  bringing  out  of  the  ab- 
dominal cavity  the  loops  to  be  anastomosed  and  pack  with  sterile  ' 


rECHNK     01     LATERAJ     W  \-  rOMOSIS. 


58l 


compresses.     F.ach  loop  is  clamped  and  the  two  clamps  laid  side  by 
side  so  as  to  bring  about  5  inches  of  the  bowel  walls  in  contact  I  Fig.  430). 


Pi  is-.  -Lateral  anastomosis; 
irst  part  of  the  through  and  through 
uture  applied.     (Binnie.) 


Fin.  433.— Lateral  anastomosis. 
in^'    last    of    the    Lembert    sutures.      Inter- 
rupted     in    this    ease,   use   the  continuous 
instead.      (Binnie.) 


The  first  line  of  suture  is  to  be  applied  nearer  the  convex  than 
he  mesenteric  border  and  should  be  about  3  inches  in  length.     Unite 


582  ENTERECTOMY.      INTESTINAL  ANASTOMOSIS. 

the  opposed   surfaces   then  by  a   sero-serous   suture.     The  line  of-- 
suture  runs  toward  the  operator,  and  when  the  line  has  reached,  say  3 
inches,  the  needle  is  left,  still  threaded,  and  temporarily  laid  aside. 

The  next  step  consists  in  making  the  openings  which  are  to  afford 
the  means  of  communication  between  the  two  loops.  A  straight 
incision  about  1/4  inch  from  and  parallel  with  this  line  of  suture  lays 
open  the  bowel  down  to  the  mucosa.  Section  of  these  superficial  coats 
leave  exposed  an  ellipse  of  mucous  membrane,  and  this  ellipse  should 
be  trimmed  out  with  the  scissors.  The  other  loop  is  opened  in  the 
same  way. 

The  adjoining  edges  are  now  to  be  coapted  by  continuous  per- 


Fig.  434. — Cross-section  of  lateral  anastomosis.     (Binnie.) 

f orating  suture  (Fig.  431).  As  this  suture  progresses  the  opposite  angle 
of  the  wound  is  reached,  but  without  interruption  it  continues  to  draw 
together  the  more  widely  separated  borders  (Fig.  432). 

When  it  has  reached  the  point  of  beginning,  the  terminal  thread 
is  knotted  with  the  first  which  was  left  long,  and  so  the  perforating 
suture  is  finished.  Remove  the  clamps,  wipe  the  bowel,  and  now 
return  to  the  sero-serous  suture  and  continue  with  that  until  the  per- 
forating sutures  are  completely  buried  or,  in  other  words,  until  the 
sero-serous  suture  has  traveled  completely  around  the  bowel  and  the 
terminal  thread  knotted  with  the  primary  suture. 

If  preferred,  this  sero-serous  suture  may  be  an  interrupted  instead  of 
a  continuous  stitch   (Fig.  433),  but  the  continuous  suture  is  more 


fECHNIC  O]     fERMINO-LATERA]     \n  VSTOMOSIS. 


583 


tepidly  passed  and  is  in  every  respei  1  as  set  ure.  The  main  thing  to  l>c 
attained,  however,  is  thai  the  serous  surfaces  be  brought  into  contacl 
■trough  the  whole  circumference  of  the  bowel. 

Fig.  434  >hnws  the  appearance  of  the  bowel  on  cross  section  after 
such  an  anastomosis.     This  method  may  l>c  modified  in  many  ways. 


Fn;.  435. — Tcrmino-lateral  anastomosis. 
Clamps  and  continuous  suture  employed. 
(Binnie.) 


Fig.  436. — Termino-lateral 
anastomosis  completed. 
(Binnie.) 


hut  exemplifies  really  the  fundamental  principles  involved  in  any  anas- 
tomosis of  the  digestive  tube.  It  is  purposely  stated  in  its  simplest 
terms  and  shorn  of  detail. 

The  technic  of  the  termino-lateral  form  of  anastomosis  does  not 
differ  in  any  essential  detail  from  that  just  described  for  the  latero- 
latrral  form  (Figs.  435  and  436). 


CHAPTER  XV. 

IMPERFORATE  ANUS. 

A  correspondent  addresses  the  editor  of  the  Journal  of  the  American 
Medical  Association  (September  8,  1906)  to  this  effect: 

"Mrs.  B.,  a  perfectly  healthy  woman  of  twenty-eight  years  of  age, 
after  a  normal  pregnancy,  gave  birth  to  a  fine  eight-pound  boy,  well 
nourished. and  healthy  looking,  and  perfect  in  every  way  except  there 
was  no  anus  nor  sign  of  any.  A  small  amount  of  meconium  was 
being  passed  through  the  urethra.  The  next  morning  a  local  surgeon 
was  called  in  counsel  and  an  incision  was  made  through  the  floor  of  the 
pelvis  and  dissected  up  along  the  coccyx,  but  no  rectum  was  found 
nor  trace  of  a  gut  until  the  sigmoid  flexure  was  reached  in  the  free 
peritoneal  cavity.  A  large  opening  in  the  sigmoid  was  followed  by 
a  discharge  of  feces.  No  attempt  was  made  to  stitch  the  gut  to  the 
wall  or  the  integument.  The  opening  was  not  closed  in  any  way  and 
no  dressing  applied,  except  that  the  nurse  was  directed  to  keep  the 
site  of  the  operation  sponged  with  a  saturated  solution  of  boracic  acid 
after  each  evacuation  of  the  bowels.  The  child  nursed  well  after  the 
operation  and  has  continued  to  do  so.  It  sleeps  nearly  all  the  time, 
but  has  had  no  elevation  of  temperature;  the  passages  come  free  and 
the  urine  is  passed  normally.  Can  you  suggest  any  means  of  treat- 
ment that  will  permit  the  child  to  grow  up  with  at  least  a  slight  control 
of  bowel  movement?" 

That  is  the  question  which  occurs  to  every  doctor  compelled  to 
deal  with  these  cases,  which  are  fortunately  rare.  The  little  being's 
life  rests  upon  the  doctor's  readiness  to  act;  and  if  it  survives,  whether 
or  not  it  carries  a  life-long  disability  depends  largely  upon  his  skill. 

It  usually  happens  in  the  course  of  such  cases  that  no  meconium 
passes  within  a  reasonable  time  after  the  baby's  birth.  It  grows 
restless,  perhaps  vomits,  and  for  the  first  time  it  is  suspected  that  there 
is  some  abnormality  about  the  rectum  or  anus,  which  an  examination 

.       584 


OP]  RA1  l«  >N     FOR    IMI'I  RFORAT1      WTS. 


5»S 


[aerifies,  it  is  imperative  to  relieve  the  condition  at  once  and  if  no 
Specialist  is  within  reach,  the  doctor  musl  undertake  it.  He  may 
ind  it  quite  easy  or  he  may  find  it  impossible. 

In  the  first   instan.  i',  the  anus  and  return  may  be  both  fully  devel 

oped,  but  in  passing  a  finger  or  probe  into  the  orifice,  a  thin  bulging 
tembrane  can  be  Felt,  apparently  almost  ready  to  hurst  when  the 
infant  cries.  A  sharp-pointed  bistoury,  wrapped  and  introduced 
along  the  finger  or  a  grooved  director,  easily  punctures  the  membrane, 
■allowed  by  a  free  passage  of  meconium;  and  thereafter  the  bowel 


PlG.  437.—  Incision  for  imperforate  anus.      (Veau.) 


readily  empties  itself.  The  mother  is  directed  to  dilate  the  opening 
daily  with  her  little  finger,  and  that,  with  an  occasional  stretching 
with  a  bougie,  is  sufficient. 

In  another  case  there  may  be  no  depression  where  the  anus  should 
be.  The  median  raphe  extends  unbroken  from  the  scrotum  to  the 
coccyx.  The  anus  is  absent  and  it  may  be  practically  impossible 
to  tell  how  high  up  in  the  pelvic  cavity  the  rectal  cul-de-sac  may  be; 
and  yet  it  is  one's  duty  to  hunt  for  it  through  the  perineum. 

Operation. — Put  the  patient  on  its  back  with  thighs  Hexed  and 
pelvis  elevated  in  short,  in  the  lithotomy  position.  Employ  a  light 
chloroform    anesthesia,  not  that  there  is  any  danger  if  the  anesthesia 


S86 


IMPERFORATE  ANUS. 


is  carefully  conducted,  unless,  indeed,  the  operation  has  been  too  long 
delayed,  but  that  a  little  straining  on  the  patient's  part  may  help  to 
locate  the  bowel. 

Make  a  median  incision  from  the  base  of  the  scrotum  or  from  near 
the  posterior  vaginal  wall  to  the  coccyx,  which  must  be  exposed  (Fig. 
437).     A  number  of  eventualities  may  present: 

(1)  One  may  find  immediately  beneath  the  skin  some  of  the  fibers 
of  the  external  sphincter,  a  favorable  indication.  Split  these  fibers 
by  blunt  dissection.     Free  incision  may  spoil  their  usefulness.     Be- 


Fig.  438. — Retention  suture.     (Veau.) 


neath  the  muscular  layer  appears  the  lobiilated  fatty  tissue  peculiar 
to  the  new-born,  which  is  to  be  next  divided.  Here  one  must  go 
slowly,  keeping  in  the  middle  line  and  all  the  time  working  toward 
the  coccyx.  The  danger  is  in  front.  If  toward  the  hollow  of  the 
sacrum,  a  fluctuating  pouch  is  felt  or  a  brownish  rounded  tumor  is 
seen,  one  breathes  easy,  knowing  that  the  imperforate  gut  is  within 
reach.  But  do  not  be  in  a  hurry  to  open  the  gut.  It  is  first  to  be 
secured  by  passing  a  suture  on  each  side  of  the  middle  line  or  by 
catching  the  bowel  wall  with  forceps.  The  suture  should  not  per- 
forate the  bowel. 

Making  gentle  traction  on  the  bowel,  proceed  to  free  it  by  careful 
blunt  dissection.     Do  not  use  knife  or  scissors  to  divide  what  seem 


DIM   R  \  l  |d\     I  i  IR     IMIM   khi|;  \  I  I      Wis. 


587 


to  be  fibrous  bands,  for  it  is  possible  thej  contain  the  blood  supply 
of  the  bowel;  and,  if  divided,  dangerous  bleeding  may  occur  or  the 
tissues  be«  ome  gangrenous. 

As  the  pouch  is  freed,  it  is  gradually  pulled  down  into  the  wound; 
and  if  they  were  Dot  passed  before,  two  sutures  are  now  passed  with 
Which  eventually  to  fasten  the  gut  to  the  skin  opening  (Fig.  438). 
Now  is  the  time  to  open  the  pouch  and  let  the  meconium  flow  out. 
It  may  require  several  minutes  for  the  bowel  to  empty  itself.  Evert 
the  mucous  membrane,  enlarging  the  bowel  wound  a  little  if  ne<  cssan 


T 

Fig.  439. — Mucocutaneous  suture.     (Veau.) 


Suture  the  mucous  membrane  directly  to  the  skin;  no  other  tissues 
should  intervene  (Fig.  439). 

Irrigate  thoroughly  and  apply  a  gauze  dressing,  which  is  changed 
as  often  as  soiled.  The  functional  result  is  often  surprisingly  good. 
Broncho-pneumonia  may  develop  when  the  operation  has  been  too 
long  delayed  and  septic  absorption  has  begun. 

(2)  The  pouch  cannot  be  drawn  down.  In  that  case  when  the  bowel 
is  opened  the  discharge  will  have  to  flow  over  the  raw  surfaces  of  the 
flesh  wound  which  will  need  to  be  kept  open  with  bougies.  Infection 
is  a  constant  danger,  not  to  speak  of  lack  of  control  of  bowel  movement. 

Belter  than  to  leave  the  wound  in  this  condition,  the  coccyx  and  a 
part  of  the  sacrum  may  be  removed  and  the  gut  brought  out  poste- 


588  IMPERFORATE  ANUS. 

riorly.  Still  better,  open  the  peritoneal  cavity,  find  and  draw  down 
a  loop  of  the  sigmoid  to  fasten  in  the  wound. 

(3)  The  pouch  cannot  be  found.  Obtain  more  room  by  resecting 
the  coccyx,  follow  the  sacrum  a  little  higher,  open  the  peritoneal  cavity 
and  search  for  the  cul-de-sac;  if  possible,  draw  it  down  into  the  wound 
and  suture. 

If  all  these  measures  fail,  there  is  nothing  to  do  but  make  an  artificial 
anus  in  the  inguinal  region.  Indeed,  there  are  those  who  advise  this 
from  the  first  with  the  idea  that  later  the  operation  for  the  construction 
of  a  normal  anal  orifice  can  be  better  undertaken. 

Tuttle  says  (Diseases  of  the  Anus,  Rectum,  and  Pelvic  Colon)  that 
where  there  is  no  evidence  that  the  rectal  pouch  can  be  easily  reached, 
and  where  the  child  is  in  an  enfeebled  condition  with  distended  ab- 
domen, fecal  vomiting,  and  nausea  in  progress,  one  should  not  hesitate 
to  choose  the  abdominal  route,  perform  an  inguinal  colotomy  at  once 
and  thus  afford  an  immediate  exit  to  the  intestinal  contents,  and  an 
escape  for  the  gases  which  are  causing  the  distention  and  the  consti- 
tutional disturbance. 

To  this  same  volume  the  reader  is  referred  for  a  full  discussion  of 
these  problems,  and  for  consideration  of  those  other  forms  of  imper- 
fect development  in  which  the  anus  has  abnormal  openings.  Such 
cases  are  not  strictly  emergencies,  for  usually  there  is  a  partial  means 
of  escape  for  the  bowel  contents. 


CHAPTER  XVI. 

TORSION  OF  THE  PEDICLE   OF  OVARIAN  OR  UTERINE 
TUMORS;  OF  THE  SPERMATIC  CORD;  OF  THE  PEDI- 
CLE OF  THE  SPLEEN;  OF  THE  OMENTUM. 

Torsion  of  the  pedicle  <>f  an  ovarian  or  uterine  tumor  may  be  either 
chronic  or  acute;  in  the  one  ease  developing  so  slowly  as  to  produce 
no  symptoms  or  even  no  effed  upon  the  tumor  unless  merely  to  in- 
hibit its  growth,  for  in  the  adhesions  are  new  sources  of  nutrition; 
in  the  second  case  developing  suddenly  and  producing  a  train  of 
symptoms  that  demand  immediate  relief.  The  acute  cases  alone, 
then,  are  to  be  regarded  as  emergencies. 

( 'ysts  of  Ih c  ovary,  especially  those  which  are  spherical,  non-adherent, 
and  connected  l>y  a  long  pedicle,  are  most  liable  to  this  accident. 

Kelly  finds  two  causes  for  this  rotation.  The  first  of  these  is  in  the 
effort  of  a  large  cyst  to  accommodate  its  convex  surface  to  ihe  con- 
cavity of  the  distended  anterior  abdominal  wall.  The  second  cause 
is  found  in  contractions  of  the  anterior  abdominal  wall,  which  act 
upon  the  part  of  the  tumor  nearest  the  middle  line.  The  effect  of 
the  force  thus  applied  is  to  rotate  the  tumor.  In  the  case  of  smaller 
tumors  lying  in  the  pelvic  cavity  it  is  likely  that  unusual  movement 
in  the  intestine  or  readjustments  of  the  pelvic  viscera  may  produce 
the  same  effect.  Kelly  quotes  Kiistner  to  the  effect  that  tumors  of 
the  right  side,  as  a  rule,  rotate  from  left  to  right,  while  left  ovarian 
tumors  rotate  from  right  to  left. 

The  diagnosis  of  acute  torsion  is  not  difficult  if  an  ovarian  cyst  is 
known  to  be  present.  If  such  a  tumor  was  previously  unsuspected 
the  certain  diagnosis  may  be  impossible,  especially  if  the  caseisseen 
late  and  general  peritonitis  is  developing. 

The  symptoms,  as  a  rule,  arise  without  warning.  There  are  severe 
colicky  pain,  vomiting,  marked  constipation,  and  the  appearances  "\ 
collapse.     Abdominal  rigidity  and  tension  rapidly  increase.     This  is 

589 


590     TORSION    OF    THE   PEDICLE    OE    OVARIAN   OR   UTERINE   TUMORS.     ' 

true  of  the  more  urgent  cases.  In  general,  the  severity  of  the  symp- 
toms vary  with  the  degree  of  torsion. 

Appendicitis  and  acute  intestinal  obstruction  present  the  greatest 
difficulties  in  differential  diagnosis  which  it  is  desirable  to  make,  not 
to  determine  the  advisability  of  operating,  but  to  determine  before- 
hand the  kind  of  operation  one  is  to  undertake.  Ranzi  (Berliner 
klin.  Wochenschrift,  Jan.  6,  1908)  reports  four  cases  of  torsion  of 
ovarian  cyst  which  were  not  differentiated  from  appendicitis,  except 
in  one  case,  before  the  operation,  and  in  this  case  by  the  pains  in  urin- 
ating. In  three  of  the  cases  there  had  evidently  been  mild  attacks 
of  torsion  which  had  subsided  and  which  had  been  diagnosed  as 
catarrhal  appendicitis. 

The  treatment  is  operative,  and,  as  has  been  indicated,  the  operation 
must  often  begin  as  an  exploratory  laparotomy,  for  though  the  symp- 
toms indicate  the  seriousness  of  the  case  they  may  not  reveal  its  char- 
acter. Delay  is  dangerous  in  these  cases,  and  seldom  will  one  regret 
having  operated  early,  for  nearly  always  the  lesions  found  exceed  the 
expectation. 

The  appearances  once  the  abdomen  is  opened  will  depend  upon  the 
size  of  the  tumor,  the  degree  of  torsion,  and  the  time  of  intervention. 
Usually  the  tumor  will  be  found  enveloped  in  loops  of  intestine  bound 
together  by  soft  adhesions  (Fig.  440). 

These  adhesions  are  to  be  carefully  separated,  and  one  must  proceed 
with  prudence  for  the  cyst  may  be  filled  with  pus  and  its  walls  may  be 
friable.  The  intestines,  detached,  are  to  be  held  out  of  the  way  with 
compresses  and  the  tumor  thus  brought  into  view.  Its  nature  may  be 
-at  once  apparent  in  spite  of  the  fact  that  it  is  discolored,  dark  red,  or 
even  black.  If  it  is  a  cyst  not  quite  so  large,  it  may  resemble  a  dilated 
cecum.  Its  attachments  are  carefully  broken  up,  and  gradually 
working  toward  its  base  the  pedicle  is  finally  defined. 

An  effort  is  now  made  to  lift  the  tumor  out  of  the  abdominal  cavity, 
and  there  need  be  no  hesitancy  in  enlarging  the  abdominal  incision 
if  necessary.  Usually  it  is  to  be  lifted  out  with  the  two  hands  applied 
to  its  base.  Occasionally  only  after  its  pedicle  is  untwisted  is  it 
possible  to  deliver  it. 

Next  the  pedicle  is  tied  near  its  point  of  implantation,  divided, 


rORSION    "I     I    I  I  k'l\l      FIBROIDS. 


591 


and  thus  the  tumor  is  removed.     It'  there  are  no  evidences  of  infection 
tin-  abdomen  is  t<>  be  1  losed  without  drainage. 

Tumors  springing  from  the  uterus  are  much  less  likely  to  become 
twisted.     Yet,  in  the  case  of  large  non-pedunculated   fibroids,  the 


Fig.  440. — Torsion  of  the  pedicle  of  an  ovarian  cyst.     {Montgomery.) 


uterus  itself  may  be  rotated  and  give  rise  to  symptoms  which  demand 
■elief.     In  such  a  case  the  intervention  may  be  quite  complex. 

In  some  instances  a  myomectomy  may  be  sufficient.     The  uterine 
wall  is  incised  over  the  long  axis  of  the  tumor,  which  is  exposed  and 


592      TORSION    OF    THE   PEDICLE    OF   OVARIAN   OR   UTERINE    TUMORS. 

peeled  out,  and  the  hemorrhage  checked  by  suture  of  the  uterine 
wound.     The  uterus  may  still  tend  to  rotate  and  may  require  fixation. 

In  still  other  instances,  hysterectomy,  either  supra-vaginal  or 
complete,  may  be  the  procedure  necessary  for  relief.  This  will  be 
the  case  when  the  condition  of  the  uterine  wall  after  removal  of  the 
tumor  would  preclude  repair. 

Harsha  reports  to  the  Chicago  Medical  Society  (Annals  of  Surgery, 
Nov.,  1905)  a  case  of  torsion  of  the  pedicle  of  an  ovarian  cyst  in  a 
woman  of  thirty-three,  who  for  several  years  at  intervals  had  had 
attacks  of  intestinal  obstruction,  accompanied  by  pain  and  vomiting, 
lasting  for  three  or  four  days. 

Her  last  attack  began  suddenly  with  pain,  vomiting,  constipation, 
tenesmus,  accompanied  by  the  symptoms  of  shock.  At  the  end  of 
four  days  the  abdomen  was  opened.  A  cyst,  the  size  of  an  orange,  with 
twisted  pedicle  was  removed.  There  was  neither  peritonitis  nor 
gangrene.     There  had  been  no  further  indications  of  obstruction. 

In  a  second  case  the  cyst  was  as  large  as  a  fetal  head  and  black  to 
within  an  inch  of  its  implantation. 

Ochsner,  commenting  on  these  cases,  says  that  symptoms  of  ob- 
struction are  not  uncommon  in  such  cases  and  that  the  history  is 
often  that  of  volvulus. 

He  cites  a  case  in  which  the  abdomen  had  been  opened  by  a  prac- 
titioner who  believed  he  was  dealing  with  intestinal  obstruction. 
Having  opened  the  abdomen,  however,  he  discovered  a  large  black 
tumor.  Disconcerted,  he  stopped  his  operation,  hurriedly  trans- 
ported the  patient  to  the  Augustana  Hospital  where  Ochsner  com- 
pleted the  work. 

The  doctor  performing  an  emergency  laparotomy  must  not  have  his 
mind  too  definitely  fixed  on  one  diagnosis.  Expecting  one  thing,  he 
must  still  have  in  view  the  possibility  of  having  to  deal  with  one  or-more 
of  a  variety  of  conditions,  and  so  will  not  be  taken  completely  unaware. 

John  Cahill  and  Sir  William  Bennett  give  the  history  of  a  case  which 
well  exemplifies  the  difficulties  of  diagnosis,  the  occasional  complexity 
of  treatment,  and  the  dangers  of  delay  (London  Lancet,  Dec.  8,  1906). 

The  patient,  aged  seventeen,  was  suddenly  seized  with  abdominal 
pain.     There  was  some  tenderness  and  resistance  over  the  right  iliac 


n  »rsk  '•-■  "i    i  in    SPi  km  \  1 1'    <  <>ki».  59  5 

fossa.  The  temperature  was  98. 8°,  the  pulse  90.  Bowels  were 
emptied  by  enemata,  but  the  pain  continued.  <  >n  the  third  day  the 
pemperature  ran  up  to  101  8°  and  the  pulse  to  120. 

An  operation  was  still  refused  until  at  the  end  of  a  week  the  patient' 
Condition   had   become   very  grave.     An   operation   for  appendicitis 

was  then  performed  and  the  appendix  found  adherent  and  filled  with 
pus,  in  addition  to  other  evidences  of  chronic  disease.  Further 
examination  revealed  a  dark,  firm  mass  occupying  the  upper  part  of 
pelvic  cavity  ami  intimately  adherent  to  the  bladder  and  uterus. 
Exposed  by  extending  the  incision,  it  proved  to  he  an  ovarian  cyst  the 
si/e  of  a  cocoanut  with  a  thick  pedicle  twisted  upon  itself  for  three- 
fourths  of  a  turn.  Its  walls  were  thin  and  blackish,  and  its  contents 
mainly  decomposed  blood.  The  cyst  was  removed  and  the  patient 
recovered. 

Dr.  Cahill,  commenting  on  the  case,  remarked  that  the  situation 
of  the  cyst  was  unusual  in  that  it  was  wedged  between  the  bladder  and 
uterus,  whereas  one  expects  to  find  such  a  tumor  in  Douglas'  pouch. 

Sir  William  Bennett  says  that  although  cases  not  infrequently 
operated  upon  for  appendicitis  prove  to  be  cases  of  torsion,  yet  the 
to.xistence  of  the  two  conditions  must  be  very  rare.  He  suggests 
that  in  this  case  the  appendicitis,  by  aggravating  the  intestinal  peris- 
talsis, had  displaced  the  tumor  with  consequent  torsion  of  its  pedicle. 

Angus  (British  Medical  Journal,  Jan.  27,  1906)  reports  an  attack 
in  a  child  of  six,  beginning  with  pain,  vomiting,  and  abdominal  dis- 
tention. By  the  rectum  a  mass  was  palpable  in  the  cul-de-sac.  A 
diagnosis  of  appendicitis  with  abscess  formation  was  made.  Opera- 
tion. The  appendix  was  inflamed  at  the  end  where  it  was  attached 
to  a  dark  cystic  swelling  in  Douglas'  pouch.  It  was  the  right  ovary 
darkly  congested,  large  as  a  duck's  egg,  and  with  twisted  pedicle. 
Its  contents  showed  it  to  be  an  ovarian  dermoid. 

TORSION  OF  THE  SPERMATIC  CORD. 

Malformations    and    imperfect    descent    predispose   to   rotations   of 
tin-  testicle- — an  accident  rare  yet  none  the  less  to  be  borne  in   mind 
as  a  possibility.     The  exciting  cause  is  usually  to  be  found  in  trauma. 
A  heavy  lift  or  strain  may  produce  it. 
38 


594      TORSION    OF   THE   PEDICLE    OF    OVARIAN   OR   UTERINE   TUMORS. 

It  is  readily  comprehended  that  an  incompletely  descended  testicle 
shifting  backward  and  forth  through  the  external  ring  could  be 
forcibly  rotated.  The  rotation  may  occur  in  two  ways:  either  the 
testicle  with  its  tunica  vaginalis  may  be  turned  or  the  testicle  alone 
may  rotate.  The  spermatic  vessels,  nerves,  and  the  vas  deferens  are 
all  involved  in  the  resulting  torsion. 

The  symptoms  range  from  moderately  severe  to  grave.  Pain, 
nausea,  vomiting,  constipation,  and  tympanites  signalize  the  attack, 
and  soon  the  signs  of  local  inflammation  appear. 

In  the  more  serious  cases  the  pain  begins  abruptly  and  persists 
It  usually  radiates  from  the  inguinal  region  and  lower  part  of  the 
abdomen,  and  may  be  intense  or  even  produce  shock.  The  con 
stipation  is  usually  relieved  by  enemata. 

The  presence  of  a  painful  tumor  in  the  inguinal  region  together  with 
the  symptoms  point  to  strangulated  hernia  and  torsion  of  the  sper 
matic  cord  equally,  and  the  differential  diagnosis  may  be  a  matter  of 
difficulty.  The  pain  is  much  more  intense  and  sudden  in  its  onset; 
than  epididymitis.  The  cord,  in  torsion,  can  be  felt  tender  and  swollen; 
it  cannot  be  felt  in  strangulated  hernia.  Of  course  in  strangulated 
hernia  the  constipation  is  absolute. 

Once  the  diagnosis  is  assured,  an  effort  to  untwist  the  cord  should 
be  made  and  occasionally  it  will  succeed.  It  is  recorded  of  patients,1 
who,  having  had  several  attacks,  learn  to  give  themselves  relief.  If 
manipulation  fails  it  is  imperative  to  operate  without  delay,  for  there 
is  danger  of  gangrene  of  the  testicle. 

An  incision  extending  from  near  the  external  ring  follows  the  cord 
down  toward  the  base  of  the  scrotum.  Layer  by  layer  the  tissues 
are  divided  until  the  tunica  vaginalis  is  reached.  The  tissues  are  often 
edematous,  reddened,  and  swollen.  The  tunica  presents  itself  as 
a  thin-walled  sac.  Open  it  and  drain  away  the'  serum  and  the  testicle 
will  be  found,  possibly  deformed,  perhaps  difficult  to  recognize,  and 
above  it  is  the  twisted  cord. 

Seize  the  testicle  and  rotate  it  from  right  to  left  in  order  to  relieve 
the  torsion  and  restore  the  circulation.  The  further  procedure  will 
depend  upon  the  integrity  of  the  testicle.  If  its  violet  color  fades, 
if  the  congestion  diminishes,  it  is  almost  certain  the  testicle  will  recover, 


TORSION    OP    I  hi     PI  I M     SP]  EEN,  595 

and  it  is  therefore  to  be  preserved.  If  ii  is  bla<  I.  or  mottled  or  ilaky, 
remove  it  by  tying  the  i  "r<l  above  the  torsion  (see  Castration).  If  its 
integrity  is  doubtful,  preserve  the  testicle  bul  provide  ample  drainage 
for  the  tunica  vaginalis. 

Lichtenstern,  of  Vienna,  reports  a  case  of  torsion  of  the  spermatic 
cord  in  a  man  of  forty  six,  w  hi.  h  began  with  lifting  a  heavy  load. 
The  scrotum  soon  became  enlarged,  and  vomiting  and  constipation 
ensued.  A  diagnosis  of  inguinal  hernia  had  been  made,  and  efforts 
to  reduce  had  failed. 

At  the  time  of  entrance  al  the  hospital  his  temperature  had  reached 
102°  and  his  pulse  was  had.  In  the  scrotum  was  a  large  tense  tumor 
and  in  the  inguinal  canal  another  smaller. 

On  opening  the  scrotum  an  enormously  swollen,  turgid  testicle 
was  found  whose  spermatic  cord  was  twisted  to  360  degrees.  Part 
of  the  omentum  was  found  at  the  internal  ring.  The  testicle  was 
untwisted  and  removed,  the  cord  resected  and  the  inguinal  canal 
closed  as  in  herniotomy. 

TORSION  OF  THE  PEDICLE  OF  THE  SPLEEN. 

The  pedicle  of  the  spleen  may  become  twisted  in  cases  of  wandering 
spleen.  As  in  other  varieties  of  torsion,  it  may  develop  slowly,  pro- 
ducing no  marked  symptoms  and  resulting  only  in  congestion  of  the 
organ  and  increase  in  size.  Developing  suddenly  it  is  accompanied 
by  the  symptoms  of  general  peritonitis  or  intestinal  obstruction,  and 
collapse.  It  may  be  mistaken  for  one  of  these  conditions.  The 
tumor  may  suggest  subphrenic  abscess. 

As  Moynihan  says,  in  the  great  majority  of  cases,  splenectomy 
is  the  better  course  to  pursue,  and  this  is  especially  true  when  throm- 
bosis of  the  splenic  vessels,  infarcts  in  the  spleen,  gangrene  or  peri- 
tonitis upon  or  around  the  spleen  are  present;  when  also  the  organ  is 
enlarged,  it  should  be  removed,  for  even  though  the  pedicle  be  untwisted, 
it  is  useless  to  try  a  splenopexy. 

The  result  of  fastening  in  place  a  small  wandering  spleen  is  doubtful. 
If  it  is  enlarged,  failure  is  certain.  Fortunately,  as  Hartmann  has 
pointed  out,  a  displaced  spleen  is  usually  not  at  all  difficult  to  remove 


596   TORSION    OF    THE   PEDICLE    OF   OVARIAN    OR   UTERINE   TUMORS. 

because  the  lengthened  pedicle  permits  of  ready  delivery;  and  the 
after-effects  are  not  so  serious  as  those  which  attend  removal  for! 
organic  disease. 

TORSION  OF  THE  OMENTUM. 

Torsion  of  the  omentum  must  naturally  be  a  rare  condition,  and 
yet  is  to  be  thought  of  when  symptoms  of  intestinal  obstruction  arise 
in  those  who  have  a  hernia  or  are  obese. 

Torsion  of  the  omentum  is  naturally  painful.  The  pain,  which  is 
probably  due  to  the  plugging  of  the  omental  vessels,  may  simulate 
appendicitis.  It  is  not  important  that  the  differential  diagnosis  is 
sometimes  not  made,  for  the  symptoms  indicate  operation. 

Rinchea  and  Corner  describe  a  case  in  the  British  Medical  Journal, 
Jan.  20,  1906.  The  patient,  a  man  of  48,  had  had  a  hernia  for  37 
years,  and  had  worn  a  truss  for  33;  the  hernia  had  been  reducible 
and  painless.  He  was  suddenly  seized  with  pain,  and  the  hernia 
became  irreducible.  The  pain  increased,  and  the  tumor  as  well, 
though  after  two  days  the  bowels  moved,  a  circumstance  which  ruled 
out  strangulated  hernia.  The  temperature  remained  990,  the  pulse 
102.  The  skin  over  the  lower  part  of  the  abdomen  and  inguinal 
region  became  reddened  and  the  region  tender.  An  incision  over 
the  inguinal  canal  found  the  tissues  inflamed,  and  on  opening  the 
hernial  sac  a  small  mass  of  omentum  was  found  twisted  on  itself  five 
times,  but  not  constricted  at  the  internal  ring.  The  mass  was  resected, 
and  the  radical  operation  for  hernia  performed. 

In  another  case,  the  patient,  a  man  of  45  with  recent  direct  hernia, 
a  mass  of  omentum  was  found,  pedunculated,  the  size  of  a  walnut, 
and  containing  a  hemorrhagic  cyst. 

Cullen,    of    Baltimore    (Johns    Hopkins    Hospital    Bulletin,    Dec.,! 
1905),  reports  a  case  occurring  in  a  very  heavy  man.     The  patient, 
a  railway  conductor,  had  found  it  necessary  to  eject  a  recalcitrant 
passenger  and  succeeded  only  after  a  struggle.     In  a  few  hours  he 
had  developed  the  symptoms  of  appendicitis. 

At  the  operation  a  gray,  vascular,  nodulated  mass  was  found  which 
ended  above  in  a  tightly  twisted  pedicle  and  which  on  removal  proved 
to  be  the  omentum. 


CHAPTER   XVII. 

RUPTURE  AND  HEMORRHAGE  OF  TUBAL 
PREGNANCY. 

Rupture  of  the  sac  of  an  ectopic  gestation  is  far  Erom  being  a  rare 

accident  (Fig.  441).  When  it  occurs,  it  is  a  major  emergency,  one  in 
which  the  doctor,  isolated  though  he  may  be,  must  act  and  without 
Belay.  Eighty-five  per  cent,  of  these  cases  operated  upon  recover; 
Eighty-five  per  cent,  of  those  treated  by  expectancy  die.  These  figures 
are  in  themselves  sufficient  argument,  but  when  we  add  that  the  gravity 


Pig.  441. — Ruptured  tubal  pregnancy.     Clot  protruding  from  sac.      (Montgomei 

of  the  condition  grows  out  of  hemorrhage,  the  reason  for  immediate  in- 
tervention must  be  admitted  by  all.  Even  In  case  the  hemorrhage 
tends  to  cease  spontaneously,  the  urgency  is  scarcely  less  pressing 
to  prevent  in  fee  lion.  For  from  a  diseased  tube  or  a  Stagnant  fecal 
current  bacteria  may  escape  to  find  a  culture  medium  in  the  blood 
fnr  in  the  peritoneal  cavity. 

That  tin-  diagnosis  of  an  extra-uterine  pregnancy,  even  when  sus- 
pected, is  difficult,  no  one  will  deny.     After  the  most  careful  examina 

597 


598  RUPTURE  AND   HEMORRHAGE    OF   TUBAL   PREGNANCY. 

tion,  one  may  not  avoid  error.     More  often,  the  condition  is  not  even 
suspected  until  rupture  occurs. 

A  tubal  pregnancy  may  be  unrecognized,  but  there  can  be  no  excuse 
for  overlooking  a  ruptured  tubal  pregnancy.  It  can  scarcely  be  mis- 
taken for  anything  else.  Even  if  we  admit  that  exact  diagnosis  may 
be  impossible,  yet  the  indications  for  intervention  are  unmistakable. 
And  that,  after  all,  is  the  important  thing.  One  does  not  do  grave 
emergency  operations  on  mere  impressions  or  suspicions  or  the  fear 
that  such  and  such  may  be  the  case. 

The  attack  comes  on  suddenly.  There  are  pain,  shock  from  the 
peritoneal  tear,  and  vomiting,  suggestive  of  acute  intestinal  obstruction. 
One  might  also  think  of  appendicitis  or  a  renal  calculus.  There  is 
often  a  bloody  uterine  discharge.  Brickner  says  of  the  pain  that  it  is 
usually  localized  over  the  site  of  the  lesion.  It  has  no  definite  char- 
acter; it  may  be  cramp-like  over  the  affected  tube;  it  may  simulate 
labor  pains;  it  may  be  sharp  and  sudden.  The  usual  symptoms  of 
pregnancy  may  be  present,  but  their  absence  does  not  argue  against 
the  extra-uterine  pregnancy.  We  have,  as  yet,  no  definite  data  by 
which  we  differentiate  between  the  various  forms  (Medical  Stand- 
ard). The  history  of  the  case  and,  finally,  the  signs  of  progressive  in- 
ternal hemorrhage  point  to  the  nature  of  the  accident.  The  pulse 
grows  more  rapid  and  feeble,  the  temperature  falls,  the  features  are 
blanched,  dyspnea  appears  and  all  the  symptoms  of  collapse.  Vaginal 
examination  completes  the  diagnosis.  One  may  find  the  uterus  but 
little  enlarged,  but  on  one  side  or  the  other,  rising  out  of  the  retro- 
uterine pouch,  a  boggy  mass  of  variable  size  is  felt.  Dixon,  of  St. 
Louis  (Interstate  Medical  Journal),  says  that  in  fifteen  cases,  he  found 
the  pregnancy  on  the  right  side  in  all  but  one,  and  this  patient  had  the 
peculiar  fortune  to  have  one  on  both  sides.  The  right  side  was  re- 
lieved by  operation,  and  six  months  later  the  left  side  necessitated  a 
second  operation.  Dixon  adds  that  rigidity  of  the  abdominal  walls 
was  present  in  most  of  these  cases,  though  the  absence  of  rigidity  is ; 
often  named  as  a  differential  diagnostic  point. 

There  may  be  an  element  of  confusion.     Vineberg,  of  New  York 
(New  York  Med.  Jour.,  Feb.  22,  1906),  reports  two  cases  out  of  his  ■ 
fifty-three  in  which  there  was  a  combined  intra-  and  extra-uterine 


OPERATION    i"i'    RUPTUR1     in    rUBAl     PREGNANCY.  -'/,, 

pregnancy.     He  notes  thai  a  persistence  of  uterine  bleeding  after  an 
operation  for  extra  uterine  pregnancy  should  suggest  tin-  possibility  of 
In  intra  uterine  gestation.     He  adds,  with  respect  t<>  diagnosis  <»f  the 
condition  generally,  that  amenorrhea,  followed  later  by  pain  and  ir 
regular  uterine  bleeding,  should  always  put  one  on  his  guard. 

From  the  history,  then,  and  from  the  physical  examination  one  must 
diagnose  the  condition.  I  >n  the  signs  of  progressive  internal  hemor- 
rhage tin-  decision  to  operate  immediately  is  based,  and  one  should 
Scarcely  ever  deem  it  too  late,  for  even  in  the  face  of  the  most  mcnat  ing 
conditions,  we  must  hold  bravely  to  the  last  resource  in  which,  even  in 
the  desperate  cases,  there  is  often  safety  and  life. 

Operation.  As  Lejars  says,  the  operation  is  moving  and  dramatic, 
hut  presents  no  especial  difficulties  if  one  but  keeps  cool  and  knows 
what  is  to  he  done. 

Instruments. — The  instruments  necessary  are  scalpel,  scissors, 
artery  forceps,  two  Long  clamp  forceps,  two  retractors,  and  curved 
needles. 

General  Anesthesia. — General  anesthesia  is  necessary  and  must  be 
closely  watched.  A  continual  hypodermoclysis  is  an  excellent  means 
of  combating  the  combined  effects  of  shock  and  anesthesia.  It  should 
not  be  begun,  however,  until  the  hemorrhage  has  been  controlled. 

Antisepsis. — It  is  scarcely  necessary  to  say  that  it  is  of  little  use  to 
save  the  patient  from  hemorrhage  to  die  a  few  days  later  from  sepsis. 
The  peritoneal  cavity,  under  the  conditions  assumed,  is  a  dangerous 
culture  medium. 

The  Trendelenburg  position  is  almost  indispensable,  and  if  necessary, 
may  be  improvised. 

Incision. — A  median  incision  extending  from  the  umbilicus  toward 
the  pubes  is  made.  Do  not  wound  the  bladder,  which  may  be  pushed 
upward  and  forward.  This,  however,  is  not  particularly  serious  unless 
tlu-  wound  should  be  overlooked.  Waste  no  time.  As  soon  as  the 
peritoneum  is  opened,  catch  its  edges  with  artery  forceps  and  enlarge 
the  orifice  upward  and  downward.  Do  not  try  to  sponge  out  the 
cavity.  Without  regarding  the  clots,  which  will  roll  out  and  which 
mask  the  viscera,  plunge  a  hand  into  the  pelvic  cavity  and  locate  the 
uterus,  which  is  easily  recognized.     To  one  side,  a  thick,  doughy  or 


600  RUPTURE  AND   HEMORRHAGE    OF   TUBAL   PREGNANCY. 

friable  mass  will  be  felt.  Slip  your  fingers  under  it,  break  the  adhesions, 
and  enucleate  it.  This  will  empty  the  retro-uterine  pouch — the  cul- 
de-sac  of  Douglas.  Feel  with  finger  and  thumb  for  the  pedicle  and, 
if  possible,  pull  the  entire  mass  up  into  the  wound  and  clamp.  If  the 
mass  is  not  adherent,  a  single  clamp  enclosing  the  broad  ligament 
from  the  outer  side  and  passing  under  to  include  the  tube  will  suffice 
(Fig.  442).     If  there  is  too  much  adhesion,  clamp  on  either  side  of  the 


Fig.  442-- 


-Forceps  applied  to  the  tubo-ovarian  pedicle. 
Trendelenburg  position.      (Veau.) 


pedicle.  When  the  clamps  are  placed,  the  chief  end  of  the  operation 
has  been  attained.  Do  not  waste  time  trying  to  catch  the  bleeding 
points,  but  ligate  en  masse. 

Ligate  the  pedicle.  With  a  blunt,  curved  needle  armed  with  No.  3 
catgut,  transfix  the  pedicle  close  to  the  cornu  of  the  uterus,  between  it 
and  the  forceps  (Fig.  443).  Ligate  and  then  carry  the  ligature  around 
the  lower  segment  of  the  pedicle  and  tie  again,  directing  the  assistant 
to  pull  up  on  the  clamp,  and  finally  carry  the  ligature  around  the  entire 


LIGATION    0]     mi     i'i  i » I «  I  i  • 


601 


mass  ami  tic  a  third  time.     Preserve  the  ends  of  the  Ligature.     Ri 

tin-  tumor  and  lift  up  the  Stump  by  means  of  the  threads  l<>  sec  if  there 

is  any  bleeding  (Fig.  111).  This  ligature  stands  between  the  patient 
and  death.  If  two  damps  have  been  used,  it  will  be  accessary  to 
■gate  "en  chaine." 

Now  clean  out  the  dots,  mop  out  the  blood,  and  lower  the  pelvisto 

drain  the  upper  part  of  the  abdominal  eavity.  The  quantity  of  Mood 
is  often  enormous.      If  the  patient    is  very  weak,  do  not  prolong  the 


Fig.  443. — First  ligature  applied.     (Vcau.) 


task  of  cleansing  it  all  out;  yet  in  the  long  run,  it  is  better  to  take  the 
time  to  cleanse  out  the  fossa  and  wipe  the  intestine  and  omentum,  lor 
then  the  abdomen  may  be  dosed  without  drainage. 

Drainage.  If  there  is  oozing,  apply  a  gauze  drain  at  the  site  ot  the 
tumor,  and  insert  three  or  four  drainage-tubes  into  different  parts  of 
the  1  avity  to  carry  out  the  blood  left  behind.  Do  not  forget  to  fix  the 
drains,  lest  they  be  lost  in  the  abdomen. 

Suture  the  wound  partially,  unless  able  to  dispense  with  drainage, 


602 


RUPTURE  AND   HEMORRHAGE    OF    TUBAL   PREGNANCY. 


in  which  case  suture  completely.  Apply  a  dry  dressing  of  gauze  and 
absorbent  cotton.  Inject  salt  solution.  After  twelve  hours,  change 
the  dressing,  which  will  probably  be  saturated;  thereafter  change 
daily.  About  the  seventh  day  the  tubes  may  be  shortened,  and  about 
the  fifteenth  day,  or  often  sooner,  altogether  removed. 

Interstitial  tubal  pregnancy  (Fig.  445)  may  occasionally  be  met  with 
and  present  complications.     A  case  described  by   O.   G.  Pfaff,   of 


Fig.  444. — Ligation  and  division  of  the  tubo-ovarian  pedicle.     {Veau.) 


Indianapolis  (Western  Clinical  Recorder,  March,  1903)  illustrates  the 
subject.  On  opening  the  abdomen  a  large  reddish  bag  presented, 
which  seemed  to  develop  from  the  right  wall  of  the  uterus,  involving  the 
right  tube.  In  order  to  minimize  the  hemorrhage  as  well  as  to  secure 
the  tumor,  the  upper  portion  of  the  broad  ligament  was  clamped  and 
another  clamp  placed  to  the  left  of  the  tumor  passing  obliquely  across 
the  fundus  and  including  the  uterine  artery.  The  sac  was  now  in- 
cised at  its  summit  and  the  fetus,  membranes,  and  placenta  turned  out. 


HYSTERECTOBTV     FOB    111  MORRB  M.I  . 


(>oi 


No  ligatures  were  required.     The  sac  was  partially  sutured,  a  drainage 
tube  fastened  in  its  cavity  and  broughl  oul  through  the  lower  angle  of 
the  abdominal  wound.     The  drainage-tube  was  removed  on  the  fifth 
day,  and  recovery  was  complete. 


Fig. 


ovarian  pregnancy.     (Montgomery.) 


Hunt  (British  Medical  Journal,  Sept.  29,  1906)  reports  a  similar 
base  operated  on  after  rupture,  and  the  hemorrhage  was  only  controlled 
after  hysterectomy.  In  some  cases,  perhaps,  as  Lejars  indicates,  ex- 
cision of  a  "  V  "-shaped  section  from  the  region  of  the  cornua  with  sub- 
sequent suture  will  succeed. 


CHAPTER  XVIII. 
CESAREAN  SECTION. 

Cesarean  section,  designed  primarily  as  an  operation  to  save  the 
babe  after  the  mother's  death,  is  to-day  of  far  broader  application. 
Without  considering  its  exact  indications,  which  for  that  matter  the 
whole  profession  is  not  yet  agreed  upon,  it  may  be  stated  broadly  that 
it  is  the  method  of  choice  when  the  child  cannot  otherwise  be  de- 
livered alive.  Unfortunately  at  the  present  time  it  is  usually  what  it 
should  not  be,  viz.,  an  emergency  operation. 

The  Technic  of  Operation.  First  Stage:  Laparotomy. — Incise 
the  abdominal  wall.  The  incision  extends  in  the  middle  line  to  within 
2  inches  of  the  pubes  and  should  be  at  least  4  inches  in  length.  If  the 
uterus  is  to  be  brought  out  of  the  abdominal  wound  it  will  require  to 
be  longer.  The  peritoneum  is  to  be  exposed  and  opened  up  in  the 
usual  manner.  The  abdominal  walls  are  often  quite  thin.  As  soon 
as  the  peritoneum  is  opened  the  uterus  pushes  into  view.  Correct 
any  lateral  deviation.  Hurriedly  wall  off  the  uterus  with  sterile  com- 
presses, or  deliver  the  uterus,  protect  with  sterile  compresses  and 
suture  the  upper  angle  of  the  peritoneal  wound. 

Second  Stage:  Incision  of  the  Uterus. — Keep  exactly  in  the  middle 
line.  Make  a  small  incision  in  the  uterus  at  the  level  of  the  lower  end 
of  the  abdominal  wound  that  you  may  not  later  encroach  upon  the 
lower  segment  of  the  uterus. 

The  peritoneum  and  superficial  muscular  layers  are  divided  with 
the  bistoury,  the  deeper  muscular  fibers  separated  with  the  fingers. 
Make  a  small  opening  in  the  mucous  membrane.  Through  this 
wound  slip  a  finger  into  the  uterus  and  on  it  as  a  guide  divide  the 
uterine  wall  with  scissors  toward  the  summit;  the  incision  should  be 
6  or  7  inches  long.  If  the  placenta  is  attached  over  the  median  line, 
cut  through  it  also.     It  makes  no  difference  if  the  work  is  done  rapidly. 

Third  Stage:  Deliver  the  Child. — Slip  the  hand  into  the  uterus. 
Grasp  the  feet,  delivering  the  breech  first.  Clamp  the  cord  in  two 
places  and  cut  between. 

604 


<  ESAR]  W    SEI  l  K)N.  605 

Fourth  Stage:  Remove  the  Membranes.  As  booh  as  the  <liil«l  is 
delivered  the  uterus  contracts  and  often  the  placenta  is  detached  at 
once.     If  not  it  must  be  peeled  off  with  the  Gingers. 

Fifth  Stage:  Suture  the  Uterus.  Repair  the  uterine  wall  with  7  or  8 
interrupted  catgut  sutures  deeply  placed  bul  not  reaching  the  mucosa; 
or  suture  the  mucosa  first.  Complete  the  repair  by  a  few  superficial 
sutures.  Suture  is  the  best  means  of  hemostasia,  but  the  bleeding  is 
usually  inconsiderable,  especially  if  the  uterus  is  brought  outside  and 
bent  toward  the  pubes. 

Sixth  Stage:  Suture  the  Abdominal  Wall. —  Repair  the  peritoneum 
with  continuous  catgut  suture;  the  Fascias  with  chromic  gut  or  plain 
catgut;  the  skin  with  silkworm-gut. 

These  are  the  principles  involved,  bared  of  details  which,  of  course, 
vary  with  the  operator  and  with  the  environment.  Examples  are  not 
wanting  in  current  literature.  A  few  will  serve  to  bring  out  practical 
points. 

Lanphear,  of  St.  Louis  (American  Jour.  Surgery,  Dec,  1906), 
formulates  a  technic  for  country  practice.  The  operator  should 
haw  a  physician  for  assistant,  or  a  trained  nurse.  The  anesthetic 
should  be  given  by  a  physician. 

Instruments. — Vaginal  retractor  (for  cleansing  the  vagina),  knife, 
scissors,  4  hemostats,  needles,  chromic  catgut  No.  2,  silkworm-gut, 
safety-pins. 

The  containers  for  the  solutions  must  be  boiled  and  singed  with 
burning  alcohol — one  for  bichloride,  1  to  2000,  one  for  alcohol,  and  one 
for  sterile  water,  a  small  dish  or  two  for  the  instruments. 

Dressings  and  Sponges. — Boil  15  yards  of  gauze  and  12  towels  free 
from  fringes. 

Preparation  of  Patient. — Pubes  and  vulva  shaved.  Abdomen 
scrubbed.  When  the  anesthesia  is  complete  scrub  the  vagina  with 
gauze  and  soap  and  water,  followed  by  alcohol. 

Preparation  of  the  Hands. — They  are  to  be  scrubbed  for  5  minutes 
before  disinfecting  the  patient  and  for  5  minutes  after,  followed  by 
immersion  in  alcohol  and  then  in  the  bichloride  solution.  Again 
sponge  the  abdomen  before  covering  the  field  with  four  sterile  towels 
fastened  with  sterile  safety-pins. 


606  CESAREAN    SECTION. 

Abdominal  Incision. — Deliver  the  uterus  and  surround  with  four 
towels  wrung  out  of  very  hot  water.  Protect  the  edges  of  the  wound 
with  sterile  towels  packed  in  around  the  uterus. 

Incise  the  uterus;  deliver  the  child;  clamp  and  cut  the  cord.  The 
anesthetist  may  now  look  after  the  child  if  there  is  no  one  else  to  do  so. 
Be  careful  in  handling  the  child  that  your  hands  do  not  come  in  con- 
tact with  anything  not  sterile.  Deliver  the  placenta,  mop  out  the 
uterus;  suture.  Lanphear  advises  a  final  row  of  Lembert  sutures  for 
the  peritoneal  covering  of  the  uterus.  Repair  the  abdominal  wall; 
dress  as  usual;  pack  the  vagina  lightly  and  treat  subsequently  as  after 
any  other  confinement.  Brown,  of  Manchester,  N.  H.,  recommends 
practically  the  same  procedure  (Americal  Jour.  Surgery,  Feb.,  1907). 
He  observes  that  the  uterus  should  be  kneaded  for  a  moment  to  stimu- 
late contraction.  He  uses  in  suturing  the  uterine  wall,  a  row  of  20-day 
chromicized  gut  sutures,  passing  through  all  the  layers  a  second  row  of 
Lembert  sutures  of  silk. 

Paul  Martin,  of  Indianapolis,  reports  a  case  (Medical  Record,  Oct. 
27,  1906).  Operated  after  12  hours  of  labor  complicated  by  eclamp- 
sia and  a  narrow  pelvis  and  in  which  the  bladder  was  greatly  distended 
and  which  could  not  be  emptied  by  catheter.  The  bladder  extended 
half-way  to  the  umbilicus.  The  uterus  was  emptied  through  a  4-inch 
incision  and  the  bleeding  controlled  by  the  assistant  who  grasped  the 
cervix.  The  uterine  sutures  employed  by  Martin  were  a  double  row 
of  interrupted  muscular  sutures  of  chromic  gut  and  a  continuous 
chromic  gut  for  the  serous  coat.  The  bladder  was  not  injured  and 
afterward  easily  emptied.     Mother  and  child  both  survived. 

T.  B.  Noble,  of  Indianapolis,  reports  a  case  operated  on  the  same  day 
as  Martin's.  Noble's  operation  was  deliberately  planned.  He 
waited  until  labor  was  well  under  way  and  operated  with  an  entirely 
satisfactory  result. 

Walker  Schell,  of  Terre  Haute  (Indiana  Medical  Journal,  Dec, 
1906),  by  section  delivered  safely  a  200-pound  mother  of  an  11  1/2 
pound  babe  after  a  three  days'  labor.  In  two  minutes  from  the  com- 
mencement of  the  operation  the  babe  was  in  the  hands  of  the  nurse. 
Schell  closes  the  uterus  with  interruped  silk  and  continuous  catgut 
suture. 


I  BSAR]  \N    SECTION.  607 

koliner  and   Anderson,  of   I  n«li:i  11a  j  m  »lis   (Indiana   Medical  Journal, 

Mart  I),  [907)  describe  an  operation.  The  bleeding  was  readil)  con 
(rolled  by  hoi  gauze  pads.  The  uterine  incision  6  inches  long.  Re 
pair  of  uterus:  (i)  Continuous  suture  through  muscle  and  mucosa 
with  No.  i  Van  Horn  plain  gut;  (2)  continuous  suture  through  muscle, 
No.  2  Van  Horn  plain  gut;  (3)  muscle  and  peritoneum,  No.  2  chromi- 
cizedj  (1)  peritoneum  with  No.  1  silk.  Patient  upon  the  twelfth  day 
without  inconvenience.     ELolmer  remarks  thai  the  general  practitioner 

should  make  his  patient  who  ma\   need  the  operation  acquainted  with 
its  nature  and   Success,  and   so  enlarge  the  domain  of  the  profession's 

benevolence. 

S.  A.  Reynolds  (( Jailbirds  Southern  Medicine,  Feb.,  1905)  reports  an 
operation  which,  as  he  says,  illustrates  the  principle  that  we  should 
never  be  afraid  to  put  forth  an  effort  to  relieve  our  patients  when 
absolutely  demanded,  however  hazardous  and  difficult  the  interven- 
tion and  however  meager  the  means  at  our  command.  Place,  a  log 
cabin  with  one  room,  lighted  by  a  lamp  without  chimney.  Patient,  a 
colored  girl  of  13  with  pelvic  diameters  less  than  2  inches;  labor  for  12 
hours  with  a  midwife  in  attendance.  Both  he  and  Dr.  Keen,  with 
whom  he  consulted,  realized  the  urgency,  but  neither  had  ever  done  a 
laparotomy.  Their  equipment  consisted  of  two  pocket  cases  of  in- 
struments, carbolic  acid,  a  few  ligatures,  an  earthen  pitcher  and  bowl, 
with  teakettle  of  hot  water.  They  sterilized  their  instruments  and 
hands  in  carbolic  solution.  Patient  was  laid  across  the  bed  with  feeton 
the  floor.  The  abdomen  washed.  While  Dr.  Keen  gave  the  chloroform 
Reynolds  made  an  incision  from  the  umbilicus  down.  The  sides  of  the 
abdomen  were  pressed  against  the  sides  of  the  uterus  to  prevent  bleed- 
ing into  the  abdominal  cavity,  and  the  uterus  opened  and  emptied. 

One  suture  was  put  in  the  uterus.  Abdominal  wall  closed  with  silk. 
On  the  fourth  day  the  temperature  was  103. 50,  pulse  150,  resp.  36,  but 
the  symptoms  of  infection  subsided  and  by  the  fourth  week  the  patient 
was  well. 

Schaute's  clinic  with  a  record  of  175  cases  furnishes  the  conclusion 
that  the  ultimate  outcome  of  these  operations  is  still  far  from  perfect, 
and  that  the  best  results  are  obtained  from  a  sagittal  incision  of  the 
uterus  made  as  high  as  possible. 


CHAPTER   XIX. 
RUPTURE  OF  THE  URETHRA.* 

By  a  fall  astride  a  hard  or  sharp-margined  object,  by  accidents  of 
saddle  or  bicycle,  by  a  kick  or  blow,  by  a  fracture  of  the  pelvis,  the 
urethra  may  be  ruptured.  The  urethral  canal  is  forced  up  against  the 
pubic  arch  or  against  the  sharp  edge  of  the  triangular  ligament,  and  is 
lacerated  while  the  more  elastic  integument  of  the  perineum  escapes. 

Any  part  of  the  urethra  may  suffer,  although  usually  only  one  part 
is  involved  in  a  given  case.  The  prognosis,  and  in  some  degree  the 
treatment,  depend  upon  the  portion  injured,  though  the  exact  location 
is  not  always  easily  determined. 

Again  the  prognosis  and  treatment  depend  upon  whether  the  rupture 
is  total  or  incomplete,  for  upon  the  degree  of  laceration  depend  the 
rapidity  of  extravasation  and  later  the  dimensions  of  the  stricture. 

These,  then,  are  the  dangers:  extravasation  of  urine,  and  in  its  wake 
suppuration,  abscess  formation,  and  general  septic  infection;  on  the 
other  hand  and  later,  stricture  formation  and  all  its  attendant 
difficulties. 

*"We  consider  it  unnecessary  to  speak  of  the  medical  treatment  which  is  abso- 
lutely valueless,  and  while  the  mechanical  treatment  has  been  in  favor  even  with 
the  surgeon,  it  must  be  condemned  if  it  becomes  a  general  procedure. 

The  introduction  of  sounds  and  catheters  into  a  lacerated  urethra  will  almost 
invariably  be  followed  by  infection  at  the  point  of  laceration,  notwithstanding  the 
aseptic  conditions  under  which  the  catheterization  is  performed.  The  general 
practitioner  has  been  accused  of  inefficiency  and  carelessness  in  sterilizing  his  in-  I 
struments.  While  this  is  true  to  some  extent,  it  will  be  seen  later,  when  speaking 
of  the  Bacteriology  of  the  Urethra,  that  a  small  aseptic  instrument  may  cause  in- 
fection because  the  traumatism  produced  by  the  passage  of  a  sound  increases  the 
virulence  of  the  urethral  flora,  which  normally  is  in  a  semi-saprophytic  state  of  life. 

On  the  other  hand,  the  general  practitioner  with  less  ability  in  the  handling  of 
sounds,  especially  when  the  uretha   is  inflamed  and  edematous,  will  cause  false 
passages,  increase  the  liability  of  stricture  at  the  point  of  laceration  and  predispose  1 
the  deep  structures  to  infection  and  its  consequences.     It  is  our  object  to  urge  1 
early  surgical  treatment  in  these  cases  and  rational  treatment  of  the  later  conse-B 
quences.     The  expression,  "traumatic  stricture,"  must  disappear  from  the  medical   J 
vocabulary  if  the  intervention  in  acute  cases  be  immediate  and  rational." — Sur-    . 
gery,  Gynecology,  Obstetrics,  Oct.,  1906.     Xeff  and  Schrayer,  Murphy's  Clinic, 
Chicago. 

608 


SYMPTOMS    OP    KM  I'll  ki     <>i     nil     I  K I  III  KA.  <;0() 

R 11  j >i  11  re-  of  the  urethra,  therefore,  is  always  ;i  serious  injury,  and  in 
order  that  its  dangers  may  It  ob>  iated,  promptness  <>i  re<  ognition  and 
intervention  is  imperative. 

The  symptoms  of  injury  to  the  urethra  arc  definite  though  varying 

in  degree  ami  an-:  retention  of  urine,  hemorrhage  from  the    urethra, 
and  perineal  tumor. 

These  symptoms,  together  with  the  history  of  the  ease,  readily  make 
the  diagnosis,  hut  only  by  a  careful  study  of  each,  recalling  at  the  Same 
time  the  anatomy  of  the  urethra,  may  one  decide  upon  the  location 
of  the  injury. 

(a)  Retention  of  urine  accompanies  in  some  degree  all  traumatic 
ruptures,  though  one  should  not  make  a  diagnosis  from  this  symptom 
alone  for  retention  may  follow  a  mere  contusion — an  interstitial 
rupture,  without  any  solution  of  the  continuity  of  the  canal  and  without 
obstruction.  It  has  its  origin  in  "shock,"  perhaps,  with  temporary 
paralysis  of  the  bladder  musculature.  In  such  a  case,  there  is  gradual 
development  of  a  perineal  tumor  from  the  contusion,  but,  on  the  other 
hand,  the  bladder  slowly  fills  and  rises  out  of  the  pelvis. 

In  a  few  hours,  the  urine  begins  to  dribble;  a  little  later  micturition 
becomes  voluntary  though  painful,  and  gradually  the  function  is 
restored  to  the  normal.  In  actual  rupture,  the  retention  is  complete 
and  continuous. 

(b)  Hemorrhage  from  the  urethra  is  indicative  of  rupture,  but  its 
amount  in  nowise  points  to  the  degree  of  urethral  destruction.  No 
inference  may  be  drawn  from  it  as  to  the  severity  of  the  lesion.  In 
fact,  the  slighter  the  hemorrhage,  the  worse  the  outlook  if  the  other 
Symptoms  are  aggravated.  For  instance,  if  the  mucous  membrane 
alone  is  torn,  the  hemorrhage  is  immediate,  perhaps  voluminous,  and 
yet  the  lesion  is  of  minor  importance.  On  the  other  hand,  if  the 
rupture  is  complete,  the  blood  pours  out  into  the  lacerated  tissues  oi 
the  perineum,  and  only  a  few  drops  may  find  their  way  through  the 
occluded  canal.  Therefore,  one  must  never  conclude  that  because 
the  hemorrhage  from  the  meatus  is  slight,  the  injury  is  slight. 

(c)  Perineal  Tumor. — There  is  always  swelling  in  some  degree  follow- 
ing contusions  of  the  perineum  whether  the  urethra  is  injured  or  not. 
The  perineal  and  scrotal  tissues  are  ecchymosed  and  the  scrotum 

39 


610  RUPTURE  OP  THE  URETHRA. 

especially  is  likely  to  be  engorged  with  exudates.  If  the  urethra  is 
ruptured  the  bladder  empties  itself  into  the  bruised  perineal  tissues, 
the  ecchymosis  rapidly  becomes  an  edema  gradually  thickening  and 
expanding.  At  first  perhaps  an  ovoid  swelling  in  the  middle  of  the  per- 
ineum, it  gradually  spreads  until  the  scrotum,  the  pelvis,  and  finally 
the  abdominal  walls  are  infiltrated,  thickened  or  edematous  to  a 
marked  degree.  But  do  not  forget  that  the  absence  of  a  perineal 
tumor  does  not  always  mean  that  the  injury  is  slight.  If  the  rupture  is 
situated  behind  the  anterior  layer  of  the  triangular  ligament  and  if 
this  is  not  torn,  the  transudates  cannot  reach  the  perineum,  for  this 
tendinous  band  limits  the  forward  movement  of  the  urine;  and  so,  taking 
the  direction  of  least  resistance,  it  percolates  through  the  cellular 
tissues  of  the  pelvic  cavity  and  passes  up  along  the  side  of  the  bladder 
to  the  abdominal  wall.  Since,  however,  the  anterior  layer  of  the  tri- 
angular ligament  is  nearly  always  torn  to  some  extent,  perineal  swelling 
is  nearly  always  present.  Slight  swelling  will  give  no  feeling  of  se- 
curity that  the  injury  is  slight.  It  is  obviously  essential  that  one  must 
have  clearly  in  mind  the  anatomy  of  the  urethra. 

THE  ANATOMY  OF  THE  URETHRA. 

Stretched  across  the  anterior  segment  of  the  pelvic  outlet,  between 
the  rami  of  the  pubes,  is  the  triangular  ligament,  dense  and  fibrous, 
and  arranged  in  two  layers,  separated  by  a  one-half  inch  space.  In 
contact  with  the  deep  or  pelvic  surface  of  the  triangular  ligament,  is 
the  apex  of  the  prostate  gland.  In  contact  with  the  superficial  or  per- 
ineal surface  is  the  bulb  of  the  urethra,  the  knobbed  posterior  ex- 
tremity of  the  corpus  spongiosum.  The  urethra  traverses  the  prostate, 
perforates  and  bridges  the  space  between  the  two  layers  of  the  tri- 
angular ligament  and  then  tunnels  the  bulb,  runs  the  length  of  the 
corpus  spongiosum,  and  emerges  at  the  glans  penis,  the  anterior 
knobbed  extremity  of  the  corpus  spongiosum.  The  part  of  the  urethra 
anterior  to  the  triangular  ligament  consists,  then,  of  two  portions, 
the  penile  and  bulbous;  the  deep  urethra  of  two,  the  prostatic  and 
membranous,  which  later  is  the  part  which  bridges  the  one-half  inch 
space  between  the  lwo  layers  of  the  triangular  ligament.  The  clinical 
manifestations  of  rupture  depend  upon  whether  the  bulbous  or  mem- 


TREATM1  \  I    "i    C0NT1  SION    01     im     I  Rl  [BRA.  'hi 

■ranous  portion  is  involved  and  in  a  minor  degree  upon  whether  the 
lupture  is  partial  or  i  omplete.     (Sec  Fig.  469). 

CON  1  1  SION    OS   THE    B1  LBOl  S    POB  l  i<>\. 

[njury  to  the  bulbous  portion  is  by  far  the  more  frequent;  il  is  the 
form  which  the  practitioner  will  nearly  always  find.  It  remains  for 
him  in  decide  whether  the  injury  is  a  contusion  or  rupture,  for  the  prog 
nosis  and  treatment  are  quite  different  in  the  two  degrees  of  injury. 
It'  the  <  ase  is  one  of  1  ontusion,  it  is  likely  the  hemorrhage  was  abundant ; 
die  patienl  complains  of  pain  and  inability  to  pass  water;  then-  is  no 

perineal  tumor  though  the  tissues  may  be  much  bruised.  After  a 
few  hours  he  begins  to  pass  water  after  painful  effort.  The  urethral 
Heeding  may  persist,  hut  the  bladder  keeps  well  emptied. 

Treatment.- — The  treatment  is  very  simple.  Keep  the  patient 
quiet,  relieve  the  pain  if  necessary  with  small  doses  of  morphia,  and 
give  some  urinary  antiseptic  such  as  urotropin. 

Do  not  pass  a  catheter.  Why  should  you?  The  bladder  empties 
■Self;  there  is  no  perineal  inlitration;  and  to  do  so  would  only  increase 
the  risk  of  infection.  The  normal  micturition  will  return  in  a  few 
davs  in  the  cases  of  mild  contusion,  and  perhaps  in  a  week  the  patient 
will  be  well.  If,  however,  in  such  a  case,  after  a  few  days  micturi 
Ion  should  become  more  painful  and  finally  impossible,  due  to 
urethral  swelling  or  spasm,  catheterization  is  indicated.  Try  a 
■Urge,  soft,  aseptic  catheter  first;  try  to  carry  it  gently  along  the  upper 
wall  of  the  urethra.  You  may  fail  and  be  forced  to  fall  back  on  a 
catheter  of  small  size,  but  in  no  case  must  violence  be  used  or  the 
attempts  prolonged.  The  catheter  may  be  left  in  if  the  introduction 
was  diftic  ult,  but  it  must  be  kept  under  constant  surveillance,  and  at 
the  first  appearance  of  a  perineal  tumor,  indicative  of  infiltration, 
operation  is  imperative.  If  a  catheter  of  small  size  has  to  be  employed, 
it  may  not  fill  the  urethra  and  there  may  be  some  dribbling  of  urine, 
Which  favors  infection.  In  such  a  case  the  catheter  remaining  in  the 
bladder  may  keep  it  empty  by  siphonage. 

(  ontusion,  with  the  formation  of  a  large  hematoma  in  the  perineum, 
might  simulate  rupture,  but  the  presence  of  a  distended  bladder  dem- 
onstrates that   the  perineal  tumor  is  not  infiltrated  urine.     In  su<  h 


612  RUPTURE  OF  THE  URETHRA. 

a  case  again,  an  attempt  should  be  made  to  pass  a  catheter  if  the 
urine  does  not  begin  to  flow  after  three  or  four  hours.  If  successful, 
the  size  of  catheter  may  be  increased  from  day  to  day. 

It  must  be  borne  in  mind  in  making  the  first  attempt  that  too  per- 
sistent effort  may  result  in  rupture  of  the  already  contused  urethra, 
or  insure  infection. 

In  case  of  failure,  you  may  follow  the  recommendation  of  Lejars, 
and  proceed  to  drain  the  bladder  by  suprapubic  puncture  and  it  may 
be,  after  a  day  or  two  when  the  swelling  has  subsided,  a  catheter  can  be 
passed  and  drainage  secured  in  that  manner  as  before,  but  hold  your- 
self ready  to  operate  at  the  first  sign  of  infiltration. 

This  line  of  treatment  can  only  be  recommended  to  those  who  are 
sure  they  can  distinguish  between  hematoma  following  contusion  and 
infiltration  following  rupture.  In  case  of  doubt,  always  treat  the  case 
as  one  of  rupture. 

RUPTURE  OF  THE  BULBOUS  PORTION. 

Urethral  hemorrhage,  rapidly  increasing  perineal  tumor  obviously 
due  to  infiltrating  urine,  and  retention  of  urine  following  injury  point 
at  once  to  some  destruction  of  the  urethral  wall. 

There  is  no  use  of  wasting  time  attempting  to  pass  a  catheter; 
prepare  at  once  for  an  external  urethrotomy.  Even  if  you  succeed 
in  passing  a  catheter,  it  will  not  prevent  extravasation  in  the  end,  as 
Reginald  Harrison  and  others  have  pointed  out.  Nor  is  there  need  to 
wait  for  additional  symptoms.  The  indications  for  operation  are  un- 
mistakable. Delay  merely  exposes  the  patient  to  all  the  risks  of 
infection.  The  end  in  view  is  to  furnish  a  free  outlet  for  the  urine  and 
if  possible  to  repair  the  ruptured  canal. 

Operation  for  External  Urethrotomy. — Provide  for  the  operation 
soft  rubber  catheters  of  various  sizes;  a  grooved  staff  or  steel  sound; 
small,  curved  needles,  silk  No.  o,  and  three  or  four  sizes  of  catgut. 

General  anesthesia  is  indispensable.  Place  the  patient  in  the  lithot- 
omy position  with  the  perineum  exposed  to  a  good  light.  The  entire 
field  must  be  disinfected  with  extreme  care. 

As  soon  as  the  patient  is  anesthetized,  an  effort  may  be  made  to 
pass  a  catheter,  and,  if  successful,  the  operation  will  be  greatly  facili- 


til'l  K  \  i  t(  IN    I  OB    Rl  l*  l  i  Rl     "l     I  •■■'  I  H8  \- 


''i  ^ 


jated.     Otherwise  pass  the  guide  as  deepl)  as  possible  without  usin^ 
i'<.r.  e,  and  let  it  be  held  in  position  by  an  assistant  who  also  supports  the 

si  rotum. 

The  median  incision  extends  from  the  base  of  the  s<  rotum  to  within 
an  inch  of  the  anus.  Divide  the  skin  and  fascia,  when  you  may  rra.  h 
an  area  filled  with  clots  and  Lacerated  tissues,  the  site  of  the  bulb  and  its 
muscular  coverings  (Fig.  446).  You  may  not  be  able  to  recognize  the 
hull)  it'  the  destruction  has  been  great,  but  after  wiping  out  the  clots 


Pic.  446. — Incision  exposing  the  bulb  of  the  urethra.     (Duval.) 

and  debris,  a  cavity  is  exposed  (Fig.  447).  Expose  the  point  of  the 
guide,  and  you  have  thus  located  the  opening  into  the  distal  half  of 
the  urethra.  Determine  the  nature  of  the  urethral  tear,  whether 
partial  or  complete.  The  subsequent  procedure  will  depend  largely 
upon  the  type  of  injury  present. 

(a)  If  you  find  rupture  of  the  lower  wall  only,  the  remnant  of 
the  upper  wall,  a  mere  band  perhaps,  will  be  a  great  help  in  the  next 
step,  which  is  to  locate  tin-  orifice  of  the  urethra  on  the  farther  side  of  the 
fear.     The  search  lor  this  opening  must  be  patient  and  minute.     Let 


6 14  RUPTURE  OF  THE  URETHRA. 

the  point  of  a  probe  or  grooved  director  follow  the  remnant  of  the 
upper  wall  backward  and  it  may  haply  engage  in  the  orifice  and  pass 
on  into  the  bladder;  if  it  does  not,  every  bit  of  the  mangled  tissue  must 
be  examined. 

Another  manoeuvre  may  be  tried:  if  you  have  a  soft-rubber  catheter 
in  the  urethra,  pull  it  down  into  the  wound  and  endeavor  to  engage 
its  point  in  the  hidden  orifice.  Once  the  orifice  is  found  and  the  cath- 
eter carried  into  the  bladder,  try  to  suture  the  urethral  wound  over  the 


Fig.  447. — The  muscular  and  erectile-tissue  of  the  bulb  divided, 
exposing  the  urethra.      (Duval.) 

catheter.  Place  lateral  sutures  of  fine  silk  or  catgut,  beginning  at 
the  upper  wall  and  suturing  toward  the  lower  where  the  separation, 
is  greatest.     If  possible,  pass  the  suture  through  the  outer  coats  only. 

(b)  If  the  rupture  is  complete  and  the  two  ends  are  widely  separated, 
the  difficulties  are  aggravated.  There  is  no  trace  of  the  upper  wall 
left  to  assist  in  the  slightest  degree  in  locating  the  orifice  of  the  prox- 
imal segment  of  the  urethra. 

"With  the  point  of  the  grooved  director,  every  small  orifice,  every 
depression,  every  fringed  tubercle  must  be  examined  in  the  hope  that 
it  represents  the  opening." 


HIM   R  \  I  |o\     I  ok'     |.M    I'll    I' R]    I  UK  A. 


6is 


[f  you  find  something  which  looks  like  mucosa  and  the  lumen  <>i 
tin-  i  anal,  introduce  the  poinl  of  your  i  atheter  ami  if  it  is  in  the  ri^ht 
track,  it  will  glide  into  tin-  bladder. 

"A  good  light,  patient  e,  perseverani  e,  ami  an  a<  i  urate  knowledge  ol 

Be  anatomical  relations  of  the  injured   parts   often    lead  to  success  in 

the  most  difficull  cases."     (Senn's  Practical  Surgery.) 


Fig.  448. — Soft  catheter  passed  into  the  bladder  after  repair 
of  the  upper  wall.      (Duval.) 

Pressure  on  the  bladder  may  sometimes  help  by  forcing  a  drop  or 
two  of  urine  through  and  thus  exposing  the  urethral  opening.  Some- 
times bleeding  from  the  ruptured  artery  of  the  bulb  will  serve  as  a 
guide  to  the  hidden  opening. 

The  incision  may  be  extended  backward  with  a  view  to  exposing  the 
■anal,  but  this  is  often  unsatisfactory  and  care  must  be  taken  not  to 
wound  the  anal  sphincter. 

If,  by  any  of  these  means,  the  orifice  is  finally  located  and  the  cath- 


6i6 


RUPTURE    OF   THE   URETHRA. 


eter  passed  into  the  bladder,  it  remains  to  adjust  and  suture  the  divided 
ends.  The  ideal  way  consists  in  making  an  end-to-end  anastomosis, 
passing  the  sutures  through  the  outer  coats  only.  Occasionally  you 
will  be  satisfied  if,  by  passing  sutures  through  all  the  coats,  you 
can  approximate,  in  some  degree,  the  two  ends,  favoring  by  that  much 
the  ultimate  restoration  of  the  canal  and  minimizing  the  stricture 
formation  (Fig.  448). 

"  In  twenty-nine  reported  cases  of  rupture  of  the  urethra  treated  by 


Fig.  449. — Repair  of  the  muscular  layers.      (Duval.) 


immediate  suture,  all  are  announced  as  successful.  These  results  are 
astonishing  and  commend  repetition."     (Bryant's  Operative  Surgery.) 

After  suture  of  the  urethral  tear,  the  perineal  wound  may  be  short- 
ened a  little  by  one  or  two  sutures,  but  ample  space  must  be  left  for 
drainage.  A  wound  unnecessarily  large  is  much  less  dangerous  than 
one  too  small  (Fig.  449) . 

Pack  the  wound  with  iodoform  gauze.  The  catheter  should  be 
left  in  the  bladder  for  three  to  four  days,  when  it  is  removed  and  a 
steel  sound  passed  thereafter  every  two  or  three  days  until  repair  is 
complete. 


SI  i-k  \i'i  BK    -  YSTOTOMY.  61 7 

(c)  What  arc  you  to  « 1  < >  in  case  patient  search  fails  to  locate  the 
bladder  end  of  the  t<»rn  1  anal  and  you  arc  unable,  therefore,  to  pass  the 
catheter  Into  the  bladder  and  to  suture .     Two  procedures  are  re<  om 

mended: 

(1)  Park  the  wound  with  iodoform  gauze  and  empty  the  bladder 
as  necessary  by  suprapubic  puncture.  Perhaps  al  a  later  examina- 
tion the  opening  may  be  found,  or,  as  will  nearly  always  happen,  the 
Madder  is  sufficiently  drained  after  a  day  or  two,  through  the  perineal 
wound. 

(2)  Do  a  suprapubic  cystotomy  and  "retrograde  catheterization." 
Where  the  general  condition  of  the  patient  and  other  circumstances 
permit,  this  procedure  is  the  better,  since  it  assures  drainage  and 
facilitates  primary  repair  by  definitely  locating  the  bladder  end  of 
the  torn  urethra  in  the  perineal  wound.  It  is  necessarily  a  delicate 
operation  and  should  not  be  undertaken  by  the  wholly  inexperienced. 

To  perform  suprapubic  cystotomy  and  retrograde  catheterization, 
begin  by  carefully  disinfecting  the  abdominal  wall.  Make  an  incision 
two  and  one-half  inches  long  in  the  middle  line,  beginning  at  the 
pubes  and  cutting  through  the  skin  and  subcutaneous  tissues  and 
the  fascias.  Retract  the  lips  of  the  wound  widely.  You  may  not 
be  able  to  distinguish  the  peritoneal  covering  of  the  bladder,  for  it  may 
be  above  the  upper  level  of  the  wound.  In  any  event,  it  must  be  pushed 
up  out  of  the  way.  Next  locate  the  bladder,  which  is  easily  felt  if  it 
is  distended;  but  if  it  is  not,  follow-  the  posterior  surface  of  the  pubes. 

Transfix  the  anterior  wall  by  a  suture  on  each  side  of  the  proposed 
line  of  incision,  and  lift  the  bladder  upward  to  the  abdominal  wound 
and  open  it  by  a  free  incision.  A  small  incision  is  a  nuisance,  while 
a  large  incision  renders  the  subsequent  steps  easier  and  is  easily  sutured 
at  the  end  of  the  operation. 

With  the  bladder  opened,  the  next  step  is  to  pass  the  catheter. 
If  possible  locate  the  urethral  orifice  in  the  badder  and  pass  the 
catheter  by  sight,  but  you  will  usually  have  to  depend  upon  touch  for 
this  procedure. 

Introduce  the  left  index  and  middle  fingers  into  the  bladder  and 
touch  the  bast'.  \ow  draw  the  lingers  forward  in  the  middle  line 
and  the  neck  of  tin-  Madder  will  be  recognized  by  its  relation  to  the 


6l8  RUPTURE  OF  THE  URETHRA. 

prostate,  and  the  urethral  opening  feels  like  a  pimple  on  the  base  of 
the  gland.  The  catheter  is  now  slipped  along  the  finger  resting  on  the 
orifice.  Once  engaged,  it  is  pushed  on  through  the  urethra  until  its 
point  emerges  in  the  perineal  wound.  Couple  it  onto  the  soft  catheter 
in  the  anterior  part  of  the  urethra  and  retract  it  through  the  abdominal 
wound,  and  by  this  means  the  catheter  in  front  is  drawn  into  place 
and  should  be  left  in  the  bladder  after  the  urethra  and  perineal 
wounds  are  sutured,  as  before  described. 

We  must  now  provide  for  the  drainage  of  the  bladder  through 
the  suprapubic  wound.  Employ  a  medium-size  catheter  and  let  it 
reach  almost  to  the  bottom  of  the  bladder  and  anchor  it  in  place 
with  a  safety-pin.  Suture  the  bladder  wound  tightly  about  the  tube. 
Repair  the  abdominal  wall,  leaving  enough  room  for  light  gauze 
packing  about  the  tube. 

"Many  elaborate  methods  of  suprapubic  drainage  are  described, 
but  this  tube  connected  to  a  long  rubber  tube  by  means  of  a  glass 
coupler  and  terminating  beneath  the  bed  in  a  bottle  filled  one-quarter 
full  of  bichloride  solution,  will  meet  all  the  requirements  of  the  case." 
(Taylor,  G.  U.  and  Venereal  Disease.) 

The  tube  may  be  replaced  by  a  smaller  one  after  two  or  three  days. 
As  soon  as  possible,  the  wound  is  allowed  to  fill  up  by  granulation  and 
the  drain  is  entirely  removed. 

RUPTURE  OF  THE  MEMBRANOUS  URETHRA. 

This  accident  is  rare  except  in  connection  with  fractures  of  the  pelvis. 
Under  any  circumstances,  it  is  even  more  dangerous  than  rupture  in 
front  of  the  triangular  ligament,  for  the  extravasated  urine  may  easily 
spread  up  into  the  pelvic  cavity  and  induce  cellulitis  and  general  in- 
fection. Examination  per  rectum  will  often  reveal  the  edema,  no 
signs  of  which  appear  in  the  perineum. 

Nothing  but  free  incision  and  drainage  through  the  perineum  is 
of  any  use. 

Finally  the  pendulous  portion  of  the  urethra  may  be  ruptured,  some- 
times in  coitus,*  and  the  hemorrhage  may  be  quite  alarming  to  the  pa- 
tient; there  may  also  be  retention  of  urine.  Usually  catheterization 
will  be  sufficient. 


CHAPTER  XX. 

ACUTE     RETENTION,     CATHETERIZATION,     SUPRAPUBIC 
PUNCTURE,  CYSTOTOMY,  URINARY  INFILTRATION. 

Every  acute  retention  of  urine  demands  immediate  relief.  It 
must  be  relieved  aot  only  on  account  of  |>aiu  and  discomfort,  but  more 
especially  to  avoid  damage  to  the  bladder  or  urethra  and  the  evil  effects 
of  sepsis.     This  rule  applies  equally  to  the  cases  due  to  temporary 

Insufficiency  of  the  Madder  musculature  and  to  those  duo  to  urethral 
obstructions. 

Urethral  obstruction  may  assume  various  forms.  In  general  prac- 
tice, it  will  usually  originate  in  one  of  three  ways:  spasm  of  the  urethra, 
enlargement  of  the  prostate  gland,  or  stricture.  Very  many  more 
times  than  we  suspect  in  those  cases  regarded  as  simple  retention  from 
Bpasm,  the  real  and  predisposing  cause  is  organic.  In  every  case 
before  instituting  measures  for  relief,  it  is  wise  to  make  minute  inquiry 
into  the  patient's  history  with  respect  to  this  function.  At  least  one 
should  be  suspicious  of  the  presence  of  stricture  and  on  his  guard. 

It  is  true  that  in  a  particular  case  certain  circumstances  tend  to 
make  one  or  the  other  of  the  causes  of  retention  the  more  probable. 
Thus  if  the  patient  is  in  a  febrile  attack  or  has  suffered  some  slight 
trauma  of  the  urethra  or  has  undergone  an  operation  on  a  region  ad- 
joining the  urinary  tract,  one  thinks  of  retention  from  urethral  spasm. 
If  the  patient  is  known  to  have  a  sexual  history,  has  been  a  votary  at  the 
shrine  of  Bacchus  and  Venus,  the  logical  inference  is  organic  stricture. 
If  the  afflicted  one  is  elderly,  one  thinks  of  enlarged  prostate,  though 
mere  age  does  not  rule  out  other  causes  of  obstruction.  One  may  be 
past  the  hey-day  of  life  and  yet  strictured,  paying  late  the  price  of 
pleasures  long  since  fled. 

But  after  all,  whether  the  predisposing  cause  is  temporary  or  per- 
manent, the  actual  exciting  cause  is  usually  congestion.  This  i>  a 
practical  point  constantly  to  he  borne  in  mind,  for   it   is   congestion 

619 


620 


CATHETERIZATION . 


which  makes  urethral  instrumentation  potent  to  produce  trouble,  and 
which  makes  strict  asepsis  an  absolute  necessity. 

CATHETERIZATION. 

The  first  measure  of  relief  to  be  tried  in  actual  retention,  if  opium 
and  a  prolonged  warm  bath  are  not  practical,  is  catheterization.  To 
meet  the  possible  indications  every  practitioner  should  be  armed. 
A  certain  equipment  is  indispensable. 

A  cylindrical  metal  case  capped  at  one  end  is  most  convenient  in 
which  to  keep  and  carry  these  instruments.  The  most  essential  are 
soft -rubber  catheters  of  various  sizes,  flexible  bougies  with  olivary  and 


Fig.  450. — Conical. 
Fig.  451. — Olivary. 


Fig.     452. —  Cylindrical. 
(Stewart.) 


\_E.HTZ.VSQNS 


Fig.  453. — Elbowed  flexible  catheter. 


■  m 


Fig.  454. — Mercier  double  elbowed  flexible  catheter. 

conical  tips,  gum  catheters  with  single  and  double  elbows  or  armed 
with  stylets,  filiform  bougies  (Figs.  450,  451,  452,  453,  454). 

Sterilization  of  these  instruments  may  be  a  problem,  except  as  to 
the  rubber  catheters,  which  may  without  injury  be  disinfected  by 
boiling.  The  other  instruments  are  best  sterilized  by  formaldehyde 
vapor  and  should  be  prepared  before  leaving  the  office  and  carried 
wrapped  in  sterile  cloths. 

Without  the  special  sterilizer,  one  must  boil  these  instruments, 
risking  eventual  injury.  They  may  be  fairly  well  cleaned  by  rubbing 
with  an  antiseptic  ointment  or  by  immersion  in  a  1-20  carbolic  or 


CATHETERIZATION,  '  i  2  i 

i  [ooo  bichloride  solution.  Previous  to  its  introduction,  anoinl  the 
catheter  with  sterile  vaseline  <>r  similar  Lubricant. 

Position  of  Patient.  -The  patient  should  lie  up«>n  a  table  high  enough 
thai  the  operator  does  not  need  t<>  stoop.  The  pelvis  should  be 
elevated  and  the  thighs  flexed  and  abducted.  Begin  by  thoroughly 
cleansing  ihc  field:  cleanse  the  penis,  the  foreskin  on  both  sides,  the 
glands  and  the  meatus,  wiping  each  part  with  a  separate  compress. 
If  possible,  irrigate  the  urethra  with  boric  add  or  normal  salt  solution. 

Whatever  condition  may  be  suspected  in  an  unexplored  urethra, 
make  the  first  attempt  at  relief  with  a  large  catheter,  seventeen  or 
eighteen  French,  which,  as  is  well  known,  excites  less  resistance  than 
one  of  smaller  size.  Standing  at  the  patient's  left  side,  hold  the  penis 
between  the  linger  and  thumb  of  the  left  hand,  elongating  it,  while 
managing  the  catheter  with  the  right.  Usually  it  is  best  to  hold  the 
instrument  parallel  with  the  groin  as  its  beak  enters  the  meatus, 
gradually  bringing  the  handle  to  the  middle  line  of  the  abdomen  as 
the  instrument  penetrates.  As  the  catheter  progresses  it  may  be  helped 
along  by  giving  it  a  slightly  boring  motion.  Proceeding  thus  gently 
but  steadily,  always  avoiding  force,  the  bladder  may  be  reached.  If 
not,  a  smaller  catheter  is  to  be  tried,  and  so  on  until  one  is  found  that 
will  enter.  If  all  these  efforts  fail  and  it  becomes  evident  that  a  prac- 
tically impermeable  stricture  is  present,  resort  must  be  had  to  filiform 
bougies,  which  may  be  bent  into  various  shapes,  bayonet  shape,  or 
corkscrew  form,  and  kept  so  by  a  thick  collodion  coating. 

A  filiform  bougie  is  passed  until  it  engages,  and  then  various  back 
and  forth,  side  to  side,  movements  are  imparted  with  the  hope  of 
finding  a  passageway  through  the  scar  tissue.  The  point  may  engage 
in  lacunae  or  in  false  passages,  and  often  it  is  useful  to  leave  the  bougie 
in  situ.  A  half-dozen  may  be  left  in  the  urethra  to  occupy  the  false 
passages,  until  happily  one  finally  passes  into  the  urethral  canal. 
Once  a  bougie  is  introduced  into  the  bladder,  it  should  be  fastened  and 
left  until  the  second  day,  when  often  it  may  be  replaced  by  a  soft 
catheter  or  a  larger  bougie.  In  the  meantime,  the  urine  trickles  past 
the  stricture  drop  by  drop,  until,  in  a  short  time,  the  distention  is 
relieved. 

If  the  retention  is  known  from  the  first  to  be  due  to  stricture,  the 


622 


CATHETERIZATION. 


procedure  may  vary  somewhat.  Valentine  and  Townsend  have 
defined  the  technic  of  emergency  dilatation  of  urethral  stricture 
in  such  a  satisfactory  manner  (American  Journal  of  Surgery,  May, 
1907)  that  it  is  transposed  for  present  use  practically  in  its  entirety. 

The  hyperesthesia  of  the  urethra,   often  so  great  an  obstacle  in 
catheterization,  is  greatly  relieved  by  filling  the  urethra  with  a  thirty - 


Fig.  455. — Lubricating  the  urethra.      (Am.  Jour.  Surgery.) 

three  per  cent,  solution  of  malaleuca  sempervirens  in  sterile  oil  and 
holding  it  for  three  to  five  minutes.  Local  or  general  anesthesia  is 
undesirable. 

No  lubricant  is  used  for  filiforms,  but  the  urethra  is  to  be  filled  with 
ten  per  cent,  suspension  of  iodoform  in  glycerin,  injecting  with  a 
sterile  glass  syringe  of  one -ounce  capacity.  The  penis  is  held  in  the 
left  hand,  the  index  finger  and  thumb  pressing  the  meatus  open.     The 


M«  »l » I  ■    HI      l\s|   R  riNG    A     I  II  II  "I'M     B II  • 


623 


tip  of  the  syringe  is  inserted  and  the  contents  slowly  injected  until 
it  can  be  fell  thai  the  urethra  is  full  (Fig.  455).  When  the  injection  is 
complete  the  finger  and  thumb  compress  the  meatus  to  prevent  the 
escape  of  any  of  the  fluid  to  make  the  fingers  or  penis  slippery. 

The  filiform  is  to  be  inserted.     A  straight  bougie,  5  French,  is  in- 
serted as  far  as  it  will  go  without   force  (Fig.  456).     A  smaller  one  is 

then   passed  alongside  the  firsl   and   the  procedure  continued  with 


Pig.  jsfj. — Inserting  a  filiform.     {American  Journal  Surgery.) 

smaller  straight  bougies  until  a  No.  1  has  been  inserted  as  far  as 
possible.  This  is  then  left  in  place  and  from  three  to  six  more  intro- 
duced, each  one  being  left  at  the  point  of  arrest. 

When  as  many  fdiforms  as  will  pass  the  meatus  without  stretching 
it  are  thus  inserted,  the  one  first  introduced  may  be  urged  slightly  for- 
ward. If  its  point  is  free  but  cannot  progress,  it  may  be  withdrawn 
and  an  angular  filiform  inserted  in  its  place.  It  should  be  gently 
rotated  to  the  right  and  left  as  obstruction  is  met  with.     If  it  makes 


624 


CATHETERIZATION. 


no  progress,  it  may  be  left  in  place  and  another  of  the  straight  filiforms 
withdrawn  to  be  replaced  by  a  bayonet  filiform.  The  bayonet  fili- 
form is  to  be  pressed  forward  and  then  withdrawn  slightly  and  again 
advanced  in  a  different  direction,  hoping  to  find  the  lumen.  If  this 
fails,  the  corkscrew  filiform  is  to  be  tried,  removing  some  of  the  straight 
filiforms  if  necessary  to  have  more  room. 

When  the  corkscrew's  tip  reaches  the  face  of  the  stricture,  it  is  to 


Fig.  457. — Kollmann  filiform  guides.      (American  Journal  Surgery.) 

be  rotated,  trying  first  the  right  spiral  and  then  the  left.  If  the  second 
one  fails,  leave  it  in  place  and  try  each  of  the  straight  ones  again,  push- 
ing it  gently  forward,  and  if  it  fails  to  enter,  withdrawing  it.  After  all 
the  straight  ones  are  tested  and  removed,  try  the  corkscrew  that  re- 
mains in  the  urethra  and  then  the  one  tried  first. 

If  all  these  manoeuvres  have, failed,  an  attempt  may  be  made  with 
the  Kollmann  guide  (Fig.  457).     A  straight  or  curved  guide  is  to  be 


Fig.  458. — Valentine-Townsend  filiform  carrier.      {American  Journal  Surgery.) 


used,  depending  upon  the  location  of  the  stricture.  It  is  passed  up 
to,  and  pressed  firmly  against  the  face  of  the  stricture,  while  a  straight 
filiform  is  introduced  and  lightly  pushed  up  against  the  stricture,  chang- 
ing the  position  of  the  guide  from  time  to  time.  If  this  attempt  with 
the  Kollmann  guide  fails,  a  metal  sound  as  large  as  will  pass  to  the  stric- 
ture by  its  own  weight  is  introduced  and  held  against  the  stricture  for 
five  minutes  or  more  and  quickly  withdrawn  and  the  urethra  refilled 


MODI     "I     \\<  BORING    \    I  [LIFORM    BOl  GIE. 


with  the  iodoform  glycerin  solution  and  all  the  manoeuvres  with  the 
liliiorms  repeated,  often  with  the  result  that  the  first  inserted  will 
traverse  the  stricture  and  enter  the  bladder  smoothly. 

The  urethroscope  is  sometimes  useful  in  locating  the  orifice,  but 
even  then  the  aliform  may  be  difficult  to  enter,  manifesting  the  "per 
vcrsity  of  things  inanimate;"  although  the  shortest  urethroscope  tube 
be  used,  the  filiform  will  cling  to  its  sides  or  will  sway  to  and  fro, 
touching   every    point    of    the   exposed 

region     except    the    orifice.        Under    the 

tin  umstances,  the  Valentine-Townsend 
filiform  carrier  (Fig.  458)  is  to  be  recom- 
mended and  its  use  is  thus  described: 

After  the  urethroscopic  tube  is  in- 
serted, the  urethral  mucosa  dried,  and 
the  light  in  place,  the  carrier,  armed  with 
a  filiform,  is  inserted.  The  lowermost 
ring  containing  the  filiform's  tip  is 
pressed  against  the  face  of  the  stricture 
at  the  point  where  its  lumen  is  visible. 
Once  fixed  by  slight  pressure,  the  filiform 
is  very  slowly  projected  into  the  exposed 
lumen.  If  it  fails  to  traverse  the  stric- 
ture, an  angular  and  then  a  corkscrew 
filiform  are  tried  as  before  described. 

Whenever  a  filiform  reaches  the  bladder, 
the  fact  is  announced  by  the  ease  with 
which  the  instrument  can  be  moved  to 
and  fro,  and  by  the  increased  desire  to 
urinate  when  the  filiform  touches  the  bladder  walls, 
urine  trickle  by  the  filiform. 

The  filiform  must  be  fastened  in  place:  No  effort  must  be  made  at  this 
time  to  pass  a  larger  instrument.  Valentine  and  Townsend  recom- 
mend the  following  method  of  holding  the  filiform  in  place: 

Two  pieces  of  sterile  cord  six  inches  long  are  used,  one  tied  about 
the  bougie  in  front  of  the  meatus  so  that  the  knot  corresponds  to  the 
dorsum  of  the  penis,  and  the  other  tied  so  thai  the  knot  corresponds 
40 


Fig.  459. — Cord  attached  to  in- 
strument in  urethra.  {American 
Journal  Surgery.) 


A  few  drops  of 


626  CATHETERIZATION. 

to  the  insertion  of  the  frenum  (Fig.  459).  "Take  the  cords  projecting 
from  one  side  of  the  glans  and  pass  them  through  one  of  the  four 
holes  of  a  common  pearl  shirt  button,  draw  the  button  upon  the  two 
joined  cords  until  it  rests  exactly  at  the  post,  coronary  sulcus.     Tie  a 


Fig.  460. — Attaching  button  to  cord.     (American  Journal  of  Surgery.) 

knot  in  each  cord  at  that  point  to  fasten  the  button  in  place"  (Fig.  460). 
Proceed  in  the  same  manner  on  the  opposite  side. 

A  cord  passing  over  the  penis  connects  the  two  buttons;  another 
passing  under  the  penis  is  threaded  on  to  the  two  buttons  and  tied, 
care  being  taben  not  to  disturb  the  position  of  the  two  buttons  (Fig. 
461).     Finally  a  cord  twelve  inches  long  is  fastened  into  the  remaining 


Fig.  461. — Uniting  cords  attached  to  button,  lateral  holes.     (American  Journal  of  Surgery.) 

hole  of  each  button,  and  carried  backward  to  be  attached  to  the  pubic 
hairs  after  Guyon's  method  (Fig.  462). 

"The  penis  is  then  to  be  dressed,  covering  it  with  an  aseptic  garment. 

"Three  layers  of  sterile  gauze  ten  inches  square  are  folded  to  form 
a  triangle.  This  is  passed  under  the  penis  with  the  base  toward  the 
scrotal  angle.     The  apex  is  tied  to  the  instrument  at  its  projection 


RI   I  I  \  ["ION    I'M      rO   EN]  \K'.l  l'    PROSTATE 


627 


prom  tin-  meatus.  The  two  angles  at  the  base  are  carried  in  front  of 
t In-  penis,  one  above  the  other,  and  their  points  arc  attached  to  the 
pubic  hairs  by  the  extremities  of  the  cords  left  after  lying  in  the 
instrument "  (Fig.  1.63). 

A  pad  of  cotton  should  cover  the  genitals,  and  the  whole  be  covered 
by  a  towel,  to  be  changed  as  often  as  soiled. 


Pig.  \<<2.     Cords  attached  to  pubic 
hairs.  (American  Jour,  of  Surgery.) 


Fig.  463. — Penis  dressed.  (American 
Journal  of  Surgery.  I 


"  While  it  is  better  that  the  patient  with  a  filiform  fixed  in  his  bladder 
remains  in  bed,  there  are  circumstances  in  which  it  is  imperative  that 
he  be  allowed  to  go  about  and  attend  to  his  occupation.  Protected 
against  the  dangers  of  retention  as  above,  this  is  permissible  unless  he 
be  engaged  at  hard  labor." 

/;/  the  rase  of  retention  due  to  enlarged  prostate,  the  mode  of  procedure 
is  quite  different  if  the  primary  effort  at  passing  a  soft  catheter  tails. 

The  prostatic  catheter  with  long  curve  may  be  tried,  passing  is  as 


628  PUNCTURE    OF   THE   BLADDER. 

deeply  as  possible  before  depressing  the  handle  between  the  thighs, 
pulling  the  penis  upward,  elongating  it  to  facilitate  the  movement  of 
the  sound.  Once  the  point  is  in  the  perineal  region,  the  handle  is  to  be 
depressed  rapidly,  at  the  same  time  pushing  the  sound  on,  hoping  in 
this  manner  to  carry  it  over  the  prostatic  projection.  No  force  must 
be  employed.  Often  the  Mercier  elbowed  or  double-elbowed  catheter 
will  surmount  the  difficulty  (see  Figs.  453  and  454). 

Sometimes  a-  large  gum  elastic  catheter  armed  with  a  stylet  may  be 
useful.  The  catheter  is  introduced  to  the  obstruction,  the  stylet 
slightly  withdrawn,  which  serves  to  tilt  the  end  of  the  catheter  and 
permits  it  to  be  pushed  on  into  the  bladder. 

In  these  cases  of  chronic  enlargement  of  the  prostrate  frequent 
catheterization  may  be  required.  As  Stewart  (Surgery,  page  653) 
says,  if  it  becomes  difficult,  if  there  is  marked  irritability  of  the  bladder, 
if  the  residual  urine  steadily  increases  in  quantity,  or  if  there  is  stone 
or  persistent  cystitis,  catheterization  must  be  abandoned  and  operation 
advised. 

PUNCTURE  OF  THE  BLADDER. 

When  catheterization  has  failed  and  relief  is  imperative,  supra- 
pubic puncture  is  the  next  resort.  It  is  in  nowise  dangerous  if  aseptic, 
except  possibly  in  those  long  strictured  or  long  troubled  with  enlarged 
prostate,  when  the  peritoneal  covering  of  the  bladder  may  approach 
the  pubes. 

Begin  with  a  careful  disinfection.  Shave  and  scrub  the  abdomen 
and  pubes.  Select  for  puncture  the  point  immediately  above  the 
pubes  in  the  middle  line  exactly.  The  instrument,  which  may  be  an 
aspirator  or  simply  a  trocar,  is  to  be  entered  at  the  point  indicated, 
without  fear  of  going  too  deep,  and  pushed  backward  and  slightly 
downward  until  resistance  ceases.  Withdraw  the  stylet  and  the  urine 
follows  in  a  steady  stream.  A  rubber  tube  may  be  attached  to  the 
trocar.  The  bladder  should  not  be  emptied  rapidly,  but  slowly, 
interrupting  the  flow  from  time  to  time.  When  the  bladder  is  emptied, 
the  trocar  is  to  be  withdrawn  with  a  rapid  movement,  and  the  opening 
covered  with  a  sterile  compress,  or,  if  quite  small,  with  collodion. 


i  JfSTOTOMY.  629 

Aseptic  puncture  may  be  pra<  tised e  or  t\\  u  e  a  day  for  a  number 

nf  days  without  serious  consequences,  and  at  the  end  of  this  time 
the  congestion  oi  the  urethra  may  I"'  relieved  and  the  urinary  function 
restored.     It",  however,  at  this  time  the  urethral  obstruction  cannot 

be  overcome,  then  one  must  proceed  to  establish  permanent  drainage. 

Permanent  drainage  is  indicated  from  the  first  if  distance  precludes 

two  or  three  daily  visits,  for  there  is  no  use  to  relieve  the  patient  by 

puncture  and  then  leave  him  to  the  danger  and  pain  of  a  new  retention, 
certain  to  oc  cur. 

Again,  if  the  urethra  has  been  lacerated  by  rough  attempts  at 
Catheterization,  and  if  to  the  symptoms  of  retention  are  added  those 
of  sepsis  and  the  signs  of  beginning  infiltration,  it  is  imperative  to  es- 
tablish permanent  drainage  of  the  bladder. 

Under  these  circumstances  the  puncture  may  be  performed  with  a 
large  trocar,  and  after  the  bladder  is  emptied  a  catheter  can  be  passed 
through  the  cannula  into  the  bladder  as  far  as  possible  and  the  cannula 
gently  withdrawn. 

The  catheter  must  be  fixed  in  position,  and  this  can  readily  be  done 
by  threads  attached  to  the  skin  with  collodion.  To  the  catheter  a 
long  rubber  tube  should  be  attached,  ending  below  in  a  vessel  con- 
taining an  antiseptic  solution.  By  this  means  a  siphonage  is  estab- 
lished and  the  bladder  kept  constantly  emptied  and  prevesical  in- 
filtration avoided. 

CYSTOTOMY. 

Permanent  drainage  through  the  suprapubic  puncture  is  often 
alone  available,  though  by  no  means  ideal.  Whenever  possible,  the 
bladder  is  to  be  opened  formally  and  the  drainage  established  by  that 
means,  nor  is  the  operation  beyond  the  skill  of  the  general  practitioner. 

No  special  equipment  is  necessary:  scalpel,  scissors,  artery  forceps, 
dissecting  forceps,  small  curved  needles.  Local  anesthesia  may  be 
employed  in  case  of  necessity,  though,  of  course,  general  anesthesia 
is  desirable.     The  region  is  to  be  carefully  prepared. 

Operation. — Begin  with  an  incision  three  inches  long  commencing 
at  the  pubes  and  extending  upward  in  the  middle  line  (Fig.  464). 
Divide  the  skin  and  fat  down  to  the  aponeurosis.     Divide  the  aponeu- 


630 


CYSTOTOMY. 


rosis  and  expose  the  prevesical  fat  (Figs.  465-466).  Draw  this  fatty 
tissue  upward,  and  with  it  the  vesical  peritoneum,  exposing  the  blad- 
der. The  bladder  appears  dark  and  globular,  marked  by  large  veins. 
In  fat  subjects  it  may  seem  deeply  situated  in  spite  of  its  distention, 
but  one  need  not  fear  to  get  into  something  else. 


Fig.  464. — Cystotomy.     Primary  incision  exposing  linea  alba. 


It  is  helpful  in  controlling  the  bladder  and  later  on  in  suturing 
next  to  pass  a  suture  on  either  side  of  the  proposed  line  of  incision. 
The  sutures  should  pass  through  only  the  superficial  tissues  and  be 
parallel  to  the  bladder  incision.  Next  proceed  to  open  the  bladder 
in  the  middle  line,  making  the  puncture  at  the  level  of  the  pubes  with 
the  cutting  edge  of  the  bistoury  turned  upward,  prolonging  the  in- 


I   VS1 \IN  . 


631 


cision  from  a  half-inch  to  an  inch.  If  the  sutures  have  not  been 
passed,  catch  up  the  edges  of  the  vesical  wound  with  forceps  while 
the  urine  Sows  out. 

The  bleeding,  often  considerable  al  first,  is  not  a  matter  for  concern 
and  ceases  spontaneously  as  the  emptied  bladder  1  ontracts. 


Fig.  465. — Partial  incision  of  the  deep  layer  of  the  sheath  of  the 
recti,  exposing  the  prevesical  fat. 


When  the  bladder  is  emptied,  douche  it  thoroughly  with  warm  sterile 
water  and  explore  its  cavity  for  possible  calculi. 

It  remains  to  suture  the  edges  of  the  bladder  wound  to  those  of 
the  skin  wound  (Fig.  467).  If  the  traction  sutures  mentioned  were 
passed,  they  may  now  be  used  to  draw  the  bladder  up  into  close  contact 


632 


CYSTOTOMY. 


with  the  abdominal  wall,  passing  them  through  the  entire  thickness, 
and  tying  them  on  the  outside. 

The  mucous  membrane  is  now  brought  in  contact  with  the  skin 
and  sutured  with  catgut  (Fig.  468).  If  the  condition  of  the  vesical 
walls  does  not  permit  the  careful  coaptation  described,  then  four  or 


Fig.  466. — Cystotomy.     Recti  separated,  prevesical  fat  exposed-. 

five  sutures  may  be  employed,  passing  through  all  the  layers  of  the 
bladder  and  abdominal  walls,  bringing  them  into  contact.  In  this 
case  a  catheter  must  be  introduced  and  siphonage  instituted.  In 
the  first  case,  where  the  skin  and  mucosa  are  exactly  coapted,  it  is 
not  necessary  to  leave  a  catheter  in  the  bladder.  The  skin  wound  is, 
of  course,  sutured  above. and  gauze  should  be  packed  around  the 
catheter.  The  after-history  will  depend  upon  the  condition  present, 
but  the  ultimate  aim  will  be  to  restore  the  urethral  functions. 


SYMPTOMS   <>r    l\l  il.i  B  \  I  [ON. 


633 


[NFILTRATH  ».\  <  >F  URINE. 

Sometimes  it  happens  that  Following  a  retention,  partial  or  com- 
plete, the  urethra  gives  way  and  the  urine  percolates  through  the 

adjoining  tissues.  Under  these  circumstances,  the  urine  is  nearly 
always  septic,  the  patient  debilitated,  and  the  conditions  are  thus  ripe 
lor  a  rapid  fatality. 


Fig.  467. — Cystotomy.      Bladder  fixed  to  the  abdominal  wall,  sutures  passing 
through  the  recti;  bladder  opened. 


Shortly  after  the  rupture  of  the  urethral  wall,  the  perineal  tissues 
become  edematous,  and  the  scrotum  and  penis  markedly  swollen. 
The  infiltration  soon  involves  the  pubic  and  hypogastric  regions. 

The  symptoms  are  those  of  sepsis:  rigors,  fever,  pulse  rapid  and 
weak,  tongue  dry,  anxious  fades,  profound  depression  generally, 
the  symptoms  depending  in  degree  upon  the  duration  of  the  accident, 


634 


INFILTRATION    OF   URINE. 


Fig.  468. — Cystotomy.     Sutures  connecting  the  edges  of  the  bladder  wound  and 
the  skin.     Repair  of  the  abdominal  wall. 


I  Ki  \i  Ml  \  I    i 'I     INFILTRATION. 


tin'  rapidity  of  the  urine'.-  spread  and  its  septii  ity.     Diffuse  phlegmon 
and  gangrene  may  rapidly  ensue. 

The  rupture  usually  OCCUTS  in  fronl  of  the  triangular  ligament — 
tin-  deep  perinea]  fascia  and  so  the  urine  moves  forward  toward 
the  scrotum  and  pubes,  which  is  tin-  direction  of   least    resistance 

[Fig.    I'.,;). 


Fig.  469. — Rupture  of  the  urethra  in  front  of  the  deep  perineal  fascia  and  at  point  of 
entrance  to  the  bulb;  showing  the  direction  which  the  infiltrating  urine  may  take  into  penis 
and  scrotum,  perineum  and  suprapubic  region.      (Veau  after  Hartmann.) 


The  treatment  has  two  ends  in  view:  to  relieve  the  burdened  tissues 
and  to  open  up  a  passage  to  the  point  of  rupture.  To  relieve  the 
engorged  tissues,  a  series  of  parallel  incisions  are  to  be  made,  extending 
beyond  the  limits  of  apparent  infiltration,  for  the  deeper  tissues  are 
always  more  widely  involved  than  the  superficial.  The  incisions 
should  be  deep  enough  to  reach  the  deep  fascia.  The  bleeding  is  not 
likely  to  be  serious,  but  any  bleeding  points  may  be  caught  up,  and  if 
the  oozing  still  persists,  the  incisions  may  be  packed  with  iodoform 
Rauze. 


636 


INFILTRATION   OF   URINE. 


To  expose  the  urethra,  put  the  patient  in  the  lithotomy  position 
and  make  an  incision  in  the  middle  line,  beginning  at  the  base  of  the 
scrotum  and  terminating  in  front  of  the  rectum  (Fig.  470).  There  is 
no  guide  but  the  middle  line,  for  the  tissues,  thickened  and  infiltrated, 
are  unrecognizable.  There  is  nothing  to  do  but  continue  to  cut, 
keeping  in  the  middle  line,  until  rewarded  by  a  spurt  of  urine. 

All  the  incisions  are  to  be  thoroughly  irrigated  with  hot  normal 
salt  solution,  the  tissues  gently  squeezed  and  the  dead  tissues  removed. 
A  compress  saturated  with  peroxide  is  next  applied,  this  covered  with 
absorbent  cotton,  and  the  whole  retained  by  a  T-bandage. 


Fig.  470. — Perineal  incision  for  infiltration  of  urine.      {Veau.) 


r  Ordinarily  drainage  is  unnecessary,  for  the  open  wounds  give  free 
escape  to  the  fluids.  Often  one  is  surprised  at  the  completeness  of 
the  repair. 

At  first  the  urine  flows  out  through  the  breach  in  the  perineum, 
but  after  a  little  while  a  catheter  may  be  passed  and  fastened  in  the 
bladder  and  the  perineal  wound  allowed  to  heal. 

Lejars  prefers  the  thermo-cautery  to  the  bistoury,  both  because  the 
hemorrhage  is  less  and  because  it  exercises  a  salutary  action  upon  the 
tissues  about  to  become  gangrenous,  but  Veau  believes  the  knife  to 
be  better,  because  it  does  not  seal  the  mouths  of  interstitial  drains. 

If,  in  the  course  of  intervention,  an  abscess  cavity  extending  up 


DRAINAGE    FOB    [NFILTRATION. 


637 


toward  the  pubes  is  found,  a  drainage  tube  musl  I"-  passed  as  bigb  as 
possible  and  fastened  in  position  (Fig.  471). 

Sometimes  it  happens  that  the  urethral  rupture  occurs  behind  the 
perinea]  fascia,  and  again  taking  the  direction  of  least  resistance,  the 
prine  may  pass  up  along  the  side  <>f  the  bladder  t<>  the  deep  layer-  oi 
the  abdominal  wall;  or  it  may  pass  downward  and  backward  into  the 


Fig.  471.— Infiltration  of  urine;  placing  drain.     (Veau.) 


■chio-rectal  fossae.  This  condition  is  all  the  more  dangerous  for 
the  reason  that  the  external  manifestations  are  often  delayed  and  in 
consequence  the  true  condition  is  not  suspected  until  too  late. 

But  whenever  a  zone  of  infiltration  is  found,  wherever  it  may  be, 
incise  it  and  reach  the  urethra  if  possible.  In  the  infra-pelvic  in- 
filtrations it  may  be  necessary  to  open  and  drain  through  the  bladder. 


CHAPTER  XXI. 
SUTURE  AND  LIGATION  OF  ARTERIES. 

In  emergency  surgery  the  suture  of  a  divided  vessel  is  occasionally 
applicable,  but  the  doctor  will  usually  prefer  ligation,  which  will  nearly 
always  suffice. 

To  suture  a  vessel,  the  blood  current  must  be  under  temporary  con- 
trol by  means  of  a  clamp  protected  with  rubber,  that  the  tunica  interna 
may  not  be  injured. 

The  vessel  wall  is  seized  with  a  fine  forceps.  The  silk  sutures  are 
placed  one-sixteenth  of  an  inch  apart  in  a  longitudinal  wound,  and  only 
the  outer  coats  are  pierced. 

If  an  end-to-end  anastomosis  is  required,  three  sutures  are  recom- 
mended by  Murphy  and  the  proximal  end  is  invaginated  in  the  distal, 
the  sutures  being  passed  first  through  the  proximal  and  finally  through 
the  distal  end  from  within  outward  and  tied. 

The  indications  for  arterial  suture  are  as  follows: 

i.    Where  ligation  might  bring  about  serious  nutritional  change. 

2.  In  all  wounds  of  large  vessels. 

3.  Operative  wounds  where  a  part  of  the  vessel  must  be  sacrificed. 

LIGATION  OF  ARTERIES. 

It  is  a  rule  almost  without  exception  that  a  divided  artery  must  be 
exposed  and  both  ends  tied. 

Occasionally,  in  the  case  of  secondary  hemorrhage,  it  will  be  im- 
possible to  secure  the  artery  at  the  site  of  the  hemorrhage  and  ligation 
at  some  point  in  the  course  of  the  artery  above  the  lesion  will  then  be 
imperative.  So  that  though  only  rarely  to  be  used  in  emergency  sur- 
gery, yet  the  technic  of  special  ligations  should  be  kept  in  mind. 

General  rules  for  all  ligations  may  be  formulated: 

1.  Put  the  patient  in  some  position  best  to  expose  the  artery  and  its 
landmarks. 

638 


Gl  M  R  \l.    Rl  LES  1  OB    I  I'M  EON. 


639 


2.  Outline  Ihe  course  of  the  vessel,  using  aniline  if  necessary. 

3.  Tie  the  vessel,  bul  avoid  tying  mar  the  origin  of  a  large  branch, 
if  possible. 

i.   I  .it  the  middle  of  the  -kin  incision  correspond  t<>  the  point  of 
ligation  and  let  its  length  depend  upon  the  depth  of  the  vessel. 

5.  Let  tin-  first  incision  include  the  skin  and  superficial  fascia;  the 
incision  in  each  succeeding  layer  should  be  the  same  length  as  the  first. 

6.  Each  structure  must  be  identified  as  exposed. 


Fig.  472. — Ligation  of  an  artery.     A.  opening  the  sheath;  B,  passing  the 
ligature;  C,  tying  the  ligature.     (Moullin.) 


7.  The  sheath  of  the  vessel  is  to  be  recognized  by  its  position,  pul- 
sation, and  feel  to  the  examining  finger. 

8.  The  sheath  is  pinched  up  in  the  form  of  a  cone,  the  base  of 
jrhich  is  incised  with  edge  of  the  scalpel  turned  away  from    he  vessel. 

9.  Through  this  small  opening  the  vessel  is  gently  detached  and 
the  aneurysm  needle  passed,  beginning  usually  on  the  side  in  relation 
with  the  vein  and  keeping  it  in  close  contact  with  the  artery  (Fi.u-  47-.)- 

10.  After  the  needle  is  threaded  and  withdrawn,  be  assured  that 
Other  structures  will  be  included  in  the  ligature. 


640 


SUTURE   AND   LIGATION    OF  ARTERIES. 


11.  Draw  the  knot  tightly  enough  to  occlude  the  lumen  of  the  vessel, 
but  not  tightly  enough  to  crush  the  inner  coat. 

12.  The  subsequent  treatment  is  that  of  an  ordinary  wound. 

THE  COMMON  CAROTID  (Fig.  473) • 
The  line  of  the  artery  corresponds  to  the  anterior  border  of  the  sterno- 

mastoid. 

The  incision  should  be  three  inches  long  in  this  line,  the  middle 

of  the  incision  corresponding  to  the  cricoid  cartilage.     Divide  the  skin, 


:2)esccnd.eiiS 
\noni  nerve 

r-~0mo-7iyold 
s\    muscte 

'  Carctid 
"" '.artery 


Inb-jm 
'/ .  vein 


'fintT  border  of  JSiermg 
Mastoid  Muscle 


Fig.  473. — -Ligation  of  the  common  carotid  and  facial  arteries.     (Moullin.) 


fascia,  platysma;  catch  the  bleeding  veins,  and  divide  the  deep  fascia 
along  the  sterno-mastoid,  exposing  the  sheath  upon  which  lies  the  de- 
scendens  hypoglossi  and  the  omo-hyoid.  Just  above  the  omo-hyoid, 
open  the  sheath  from  the  inner  side  so  as  to  avoid  the  internal  jugular. 
Pass  the  needle  from  outside,  also  to  avoid  the  internal  jugular. 


LIGATION  01     I  in     SUBCLAVIAN.  6  |  I 

EXTERNAL  CAR<  'III*. 

Line.     Continuation  of  the  common  carotid. 

Incision.     From  the  angle  of  the  jaw  to  the  thyroid  cartilage,  divid 
ing  the  skin,  fast  ia,  and  platysma.     Ligate  divided  veins. 

Divide  the  deep  fascia,  exposing  the  sterno  mastoid,  which  is  to  be 
^tr acted.  Locate  the  posterior  belly  of  the  digastric,  the  hypoglossal 
ftrve,  and  the  tip  of  the  cornu  of  the  hyoid. 

Expose  the  artery  opposite  the  cornu;  pass  the  ligature  between  the 
juperior  thyroid  and  the  lingual  arteries,  avoiding  the  decendens  hypo 
glossi  and  the  superior  laryngeal  nerve  behind.  The  operation  pre 
supposes  patience  and  a  thorough  knowledge  of  the  anatomy. 
Through  this  same  incision  the  superior  thyroid,  the  lingual,  the 
facial,  the  occipital,  and  the  ascending  pharyngeal  arteries  may  be  tied 
at  their  origin. 

LINGUAL  (Beneath  the  Hyoglossus). 

Position. — Place  the  patient  on  his  back,  turn  the  head  to  the  oppo- 
site side  and  raise  the  chin  (Fig.  474). 

Incision. — Curved,  its  center  just  over  the  greater  cornu  of  the  hyoid, 
extending  from  the  symphysis  of  the  chin  to  the  angle  of  the  jaw. 
Divide  the  skin,  superficial  fascia,  platysma  and  deep  fascia.  Ligate 
the  numerous  veins  which  may  be  divided.  Locate  the  lower  border 
of  the  submaxillary  gland  and  divide  its  fascia,  thus  exposing  it,  and 
lift  it  upward  out  of  the  way. 

Develop  the  mylo-hyoid;  also  the  two  bellies  of  the  digastric  and 
draw  them  down  firmly.  In  the  bottom  of  the  wound  is  the  hyoglos- 
sus muscle.  Identify  the  hypoglossal  nerve  with  the  lingual  vein, 
which  cross  the  hyoglossus.  Incise  the  hyoglossus  below,  and  parallel 
with,  the  hypoglossal  nerve.  Incising  carefully,  the  artery  bulges  into 
the  wound.  Ligate  the  artery  on  the  proximal  side  of  the  dorsalis 
linguae. 

SUBCLAVIAN  (Third  Portion). 

Position.     Plate  the  patient  on  his  back  with  shoulders  raised,  head 
turned  to  opposite  side,  and  angle  of  shoulder  depressed  (Fig.  474). 
Incision. — From  the  posterior  border  of  the  sterno-mastoid,  over  the 
41 


642 


SUTURE  AND    LIGATION    OF  ARTERIES. 


clavicle,  to  the  anterior  border  of  the  trapezius,  drawing  the  skin  down 
first  to  prevent  wounding  the  external  jugular.  Relax  the  skin.  The 
incision  now  lies  one-half  inch  above  the  clavicle.  If  more  room  is 
needed,  partially  divide  the  trapezius  and  sterno-mastoid.  Divide 
the  deep  fascia  and  ligate  veins. 

If  the  transversalis  colli  or  the  suprascapular  arteries  present,  draw 
them  to  one  side. 


Fig.  474. — Ligation  of  the  subclavian  and  lingual  arteries.      (Moullin.) 


Now  identify  the  scalenus  anticus  muscle — a  very  important  step,! 
as  it  is  the  guide  to  the  artery.  Follow  the  external  border  of  the, 
muscle  down  to  the  first  rib  and  there  the  pulsations  of  the  artery 
will  be  felt. 

Identify  the  lowest  cord  of  the  brachial  plexus,  which,  as  well  as  the 
pleura  and  the  subclavian  vein,  must  be  avoided  in  passing  the  ligature. 


LIGATION    "I      I  III      UK  \<  III  \l .. 


THE  AXILLARY  (Third  Portion). 
Position.     Patient  supine,  shoulders  raised,  arm  at  a  right  angle; 
■perator  between  arm  and  body  (Fig.  .175). 
Incision.    -Along  the  line  of  junction  of  the  middle  and  anterior 

third  of  the  floor  of  the  spa<  e. 

I  >i\  ide  the  skin  and  fascia  and  expose  the  inner  border  of  the  coraco- 
jrachialis.  Draw  the  coraco-brachialis,  the  median  and  musculo- 
cutaneous nerves  outward,  the  ulnar  and  internal  cutaneous  nerves  in- 
ward.    Avoid  the  basilic  and  axillary  veins. 


f*TtTe/>-Tnrtte&ia7t*  mutclf 


? /n'<rr  J'7^-  f~u/an£OU3  nerve. 


Fir..  475. — Ligation  of  the  axillary  artery-      (Moullin.) 


BRACHIAL  (In  the  Middle  of  Arm). 
(See  Operation  for  Exposure  of  Median  Nerve.) 

BRACHIAL  (Bend  of  Elbow). 

Position. — Limb  extended  and  abducted,  operator  outside  of  arm 
(Fig.  476). 

Incision. — Follow  the  internal  border  of  the  bicipital  tendon,  the 
center  corresponding  to  the  bend  of  the  elbow.  Divide  the  skin  and 
superficial  fascia.  Isolate  the  median  basilic  vein  and  the  internal 
cutaneous  nerve,  retracting  them  inward.  Next  divide  the  deep  and 
the  bicipital  fascia  and  beneath  this  latter  lies  the  artery  with  its  venae 
■Unites,  the  median  nerve  to  the  inner  side. 

Do  not  neglect  to  repair  the  bicipital  fascia. 


644 


SUTURE   AND   LIGATION    OF  ARTERIES. 


RADIAL  (In  the  Upper  Third  of  Forearm). 

Position.— Hand  supine,  surgeon  to  outside  cutting  downward  (on 
the  right)  (Fig.  477)- 

Incision.— Along  the  inner  border  of  the  supinator  longus  for  three 
inches,  dividing  the  skin  and  superficial  fascia.     Divide  the  deep  fas- 

Tenrfi nous  £]wneurosi* 
divided 


Fig.  476.— Ligation  of  the  brachial  at  head  of  the  elbow;  the  median  basilic  vein 
and  internal  cutaneous  nerve  drawn  inward.      (Moulhn.) 


Supinator  longus 


Fig.  477. — Ligation  of  the  radial  artery.     In  the  floor  of  the  wound  is  the  pronator 
radii  teres.     The  nerve  lies  some  distance  to  the  radial  side.      (Moullin.) 

cia  and  separate  the  supinator  longus  and  pronator  radii  teres.     The 
artery  lies  under  the  border  of  the  supinator  longus  with  the  nerve  to ; 
the  outer  side. 

RADIAL  (At  Wrist). 
Position. — The  position  is  the  same  as  before. 

Incision. — The  incision  is  along  the  supinator  tendon.     Avoid  the 
radial  vein  and  the  superficialis  vote  artery.     Divide  the  deep  fascia 


LIGATION    OF     I  III      II  \H>K.\! 


645 


;in<l  separate  the  tendons  of  the  supinator  longus  and  Bezor  carpii 
radialis  and  between  them  lies  the  artery  and  its  venae  1  omites. 

ULNAR  (At  Wrist). 
(See  Exposure  of  Ulnar  Nerve,  page  }oi.) 

3 


S/icrmaOc  Cent 


fce/i fascia 
SarCcriua  musrh, 


Fig.  478. — Ligation  of  external  iliac  and  femoral  arteries.     (Moullin.) 

SUPERFICIAL  FEMORAL  (At  Apex  of  Scarpa's  Triangle). 
Position. — Thigh    slightly    Hexed,    rotated    externally,    abducted; 
surgeon  to  outer  side  (Fig.  478). 

Incision. — Three  inches  long,   with   center  over  apex  of  triangle. 


646 


SUTURE  AND   LIGATION    OF  ARTERIES. 


Divide  the   skin  and  superficial  fascia.     Avoid  the  long  saphenous 
vein.     Divide  the  deep  fascia  and  draw  the  sartorius  outward;  the) 
adductor  longus,  inward.     Avoid  the  internal  cutaneous  and  the  long 
saphenous  nerves.     The  vein  lies  to  the  inner  side  and  a  little  behind 
the  artery. 

FEMORAL  (In  Hunter's  Canal). 

Position. — The  position  is  the  same  as  before. 

Incision. — Three  inches  in  the  line  of  the  artery  in  the  middle  third 
of  the  thigh.     Divide  the  skin  and  superficial  fascia.     Avoid  the  in- 


Tibialis  anticus 


Fig.  479.- 


-Ligation  of  the  anterior  tibial  antery. 
the  fibular  side.      (Moullin.) 


The  nerve  lies  to 


ternal  cutaneous  nerve  and  the  long  saphenous  vein.  Divide  the  deep 
fascia,  expose  the  sartorius  and  draw  it  inward.  Incise  the  roof  of 
the  canal,  but  do  not  wound  the  long  saphenous  nerve  which  is  just 
beneath.     Draw  it  inward  and  expose  the  sheath  of  the  vessels. 

ANTERIOR  TIBIAL  (Middle  Third). 

Position. — Thighs  extended,  leg  turned  inward  and  the  foot  extended 
to  indicate  the  position  of  the  tibialis  anticus  muscle. 

Incision. — Four  or  five  inches  long  in  the  line  drawn  from  the  head 
of  the  fibula  to  the  middle  of  the  front  of  the  ankle-joint  (Fig.  479). 
Expose  the  fascia.  Divide  it  in  the  same  line.  By  the  sense  of  touch 
locate  the  septum  between  the  tibialis  anticus  and  extensor  longus 
digitorum.     Flex  the  foot  to  permit  the  separation  of  these  muscles, 


LIG  \  I  lu\    oi     i  in     POSTERIOR    TIBIAL. 


''17 


and  follow  the  septum  down  to  the  artery.     The  nerve  is  to  the  fronl 
Bid  outer  side.     Pass  the  ligature  from  without  inward. 

\\  II  RK  >u  TIBIAL  (Lower  Third). 

Position.     Same  as  above. 

/;/<  ision.     Lot  ate  the  lend  on  of  the  tibialis  anti<  us;  along  its  external 
border  divide  the  skin  for   three  inches.     Find  the  septum  between 


Fir..  480. — Ligation  of  the  posterior  tibial  artery.     The  gastrocnemius  retracted; 
the  soleus  divided.     (Moullin.) 

the  tibialis  and  the  extensor  proprius  hallucis.  In  this  space  lies 
the  artery  with  the  nerve  to  the  front  and  outer  side.  Pass  the  liga- 
ture from  without  inward. 

DORSALIS  PEDIS. 

Position. — Patient  on  back  with  foot  extended  and  resting  on  heel. 

Incision. — Two  inches  long  beginning  at  the  middle  of  the  lower 
border  of  the  annular  ligament.  Expose  and  separate  the  tendons  of 
the  extensor  proprius  hallucis  and  extensor  longus  digitorum;  the 
artery  is  seen  lying  upon  the  tarsal  ligaments.  The  nerve  lies  to  the 
fibular  side.     Pass  the  ligature  from  without  inward. 

POSTERIOR  TIBIAL  (Middle  Third). 
Position. — Patient  on  back;  leg  and  thigh  Hexed;  thigh  rotated  out- 
ward so  (hat  leg  lies  on  its  outer  side  (Fig.  480). 

Incision. — Four  inches  long,  along  the  line  three-fourths  inch  be- 


648 


SUTURE   AND   LIGATION    OF  ARTERIES. 


hind  the  internal  border  of  the  tibia.  Expose  and  divide  the  deep' 
fascia.  Expose  and  develop  the  inner  border  of  the  gastrocnemius;  re-i 
tract  and  thus  expose  the  soleus  attached  to  the  inner  border  of  the 
tibia.  Divide  the  soleus  vertically,  and  at  the  bottom  of  the  wound  is 
seen  the  yellow  fibrous  aponeurosis  which  covers  the  vessels  and  deeper 
layer  of  muscles.  Divide  the  aponeurosis  about  one  and  one-half 
inches  from  the  internal  border  of  the  tibia  and  expose  the  artery. 
Draw  the  nerve  to  the  outer  side  and  pass  the  ligature  from  without 
inward. 


Fig.  481.— Ligation  of  the  posterior  tibial  behind  the  ankle.      (Moullin.) 

POSTERIOR  TIBIAL  (At  the  Ankle). 

Position.— Turn  the  foot  on  its  outer  surface  (Fig.  481). 

Incision.— Curved,  three  inches  long,  with  center  midway  between 
malleolus  and  the  inner  tuberosity  of  the  os  calcis.  Divide  the  fascia 
and  the  internal  annular  ligament  cautiously.  The  artery  is  just  be- 
neath the  ligament.  Separate  the  veins  and  pass  the  ligature  from 
without  inward. 


CHAPTER  XXII. 

SOME  PRACTICAL  AMPUTATIONS. 

The  primary  aim  of  an  amputation  is  to  conserve  the  life  or  health 

of  the  patient;  the  secondary  aim  is  to  conserve,  as  much  as  possible, 
the  function  of  the  member.  The  first  requires  that  as  much  as  m ■<  es 
sary  be  removed;  the  second,  that  no  more  than  necessary  be  removed. 
The  good  surgeon  will  always  adjust  and  harmonize  these  two  prin- 
ciples and  they  will  determine  the  time  and  technic  of  the  particular 
operation. 

The  time  element  is  of  especial  concern  in  traumatism  and  gangrene, 
for  if  the  operation  is  done  too  early,  too  much  may  be  removed  in 
one  case  and  too  little  in  the  other.  In  traumatism,  tissue  that  at 
first  sight  seemed  beyond  remedy  may  survive;  in  gangrene,  tissue 
that  seemed  viable  may  be  left,  only  to  necessitate  another  dangerous 
operation;  so  that  following  traumatism  it  is  better  not  to  operate 
until  the  limit  of  the  devitalized  tissue  has  been  definitely  determined; 
and  in  the  case  of  gangrene,  until  the  line  of  demarcation  has  definitely 
formed. 

The  technic  is  principally  concerned  with  conservation  of  function, 
and  looks  to  the  formation  of  a  good  stump.  "A  stump  to  be  service- 
able, should  be  sound,  unirritable,  with  good  circulation  and  abundant 
leverage"  (Bryant,  Operative  Surgery).  To  produce  a  stump  with 
these  qualities  requires  prevision  of  the  flaps,  particularly  their  shape, 
length,  and  vascularity.  Upon  their  shape  will  depend  the  position 
which  the  cicatrix  will  take;  upon  their  length,  the  comfortable  ad- 
justment of  skin  and  bone;  upon  their  vascularity,  the  prompt  repair, 
proper  nutrition,  and  subsequent  freedom  from  disease. 

The  cicatrix  should  fall  where  it  will  be  least  subject  to  pressure  and 
friction  wherever  that  may  be  done  without  the  sacrifice  of  useful 
tissues.  In  determining  the  position  of  the  cicatrix,  one  must  then 
consider  the  occupation  of  the  patient  and  the  possibility  of  an  arti- 
ficial limb  being  worn. 

649 


650  SOME   PRACTICAL  AMPUTATIONS. 

In  the  case  of  the  leg,  for  example,  the  greatest  tension  might  fall 
on  the  end  of  the  stump,  and  a  scar  there  be  some  source  of  annoyance; 
in  the  case  of  an  arm,  more  pressure  might  fall  on  the  side,  from  arti- 
ficial appliances,  and  an  end  scar  would  therefore  be  more  satisfactory. 
Nerves  likely  to  be  pinched  up  in  the  cicatrix  should  always  be  resected. 
The  ends  of  severed  tendons  should  likewise  be  resected,  but  not  so 
high  that  their  empty  sheaths  may  be  left  to  favor  the  lodgment  of 
infection. 

That  the  stump  may  be  sound  and  uniform  in  its  outline,  it  is  neces- 
sary that  the  different  degrees  of  contractility  of  the  various  groups  of 
divided  muscles  be  known  and  their  division  accomplished  accordingly, 
so  that  finally  their  ends  may  occupy  the  same  level.  The  bones  must 
also  be  sawed  squarely  and  care  taken  that  the  division  is  not  com- 
pleted by  fracture.  The  periosteum  also  must  not  be  too  roughly 
handled. 

The  technic  is  concerned  also  with  the  prevention  of  hemorrhage. 
This  is  best  secured  by  first  elevating  the  limb  for  several  minutes  and 
then  applying  an  Esmarch  tube  above  the  site  of  the  operation. 

After  the  section  of  the  limb  is  completed  and  the  large  vessels  se- 
cured and  ligated,  the  tube  must  be  removed  and  each  bleeding  point 
ligated  separately.  The  tube  has  the  disadvantage  that  there  is  nearly 
always  a  temporary  vasomotor  paralysis  due  to  the  pressure,  and  on 
that  account  the  oozing  is  considerable. 

The  occasional  surgeon  will  be  called  upon  to  do  amputations  under 
two  entirely  different  circumstances,  and  his  mode  of  procedure  will 
be  quite  different  in  the  two  cases.  In  one  case,  he  will  attempt 
the  typical  amputation  of  the  text-book;  in  the  other,  his  sole  guide 
will  be  the  preservation  of  tissue:  he  will  do  an  atypical  amputation. 

(A)  The  soft  parts  are  more  extensively  destroyed  than  the 
bone.  This  is  nearly  always  the  case  in  traumatism  and  always  the 
case  in  gangrene.  The  site  of  amputation  will  depend  upon  the  limit 
of  the  sound  skin;  the  rule  is  to  remove  none  of  the  healthy  soft  parts; 
the  line  of  incision  should  follow  the  line  of  demarcation,  and  having 
fashioned  the  flap  following  this  indication,  divide  the  bone  high 
enough  to  accommodate  the  flaps,  and  no  higher.  (See  also  Injuries 
to  the  Extremities.) 


wiim   I  \  I  Ion    i»l     FINGERS. 


651 


(H)  In  case  the  bone  is  more  extensively  destroyed  than  the 
soft  parts,  as  in  tuberculosis,  sarcoma,  etc.,  one  bas  more  option;  he 

can  fashion  the  flaps  in  any  manner  desired,  for  usually  nun  h  tli.it   is 

bealthy  will  bave  in  lie  removed.    Tin-  position  of  tin-  i  i<  atru  1  an  be 
determined  and  such  is  the  typical  amputation. 

FINGER  AMPUTATIONS. 

Practical  anatomical  points  (Jacobson,  Operative  Surgery): 
"The  three  creases  in  front  almost  correspond  to  the  joints.     The 
lower  crease  is  just  above  the  joint;  the  middle  is  opposite  the  joint;  the 
highest,   nearly  3/4    of    an   inch   distal   to  the  metacarpophalangeal 
joint. 

"The  prominence  of  the  knuckles  is  formed  by  the  higher  of  the  two 
bones;  by  the  head  of  the  metacarpal  bone,  the  bead  of  the  first  phalanx, 
the  head  of  the  second  phalanx  for  the  three  joints  respectively. 


Fig.  482. — Typical  amputation  of  finger;  palmar  flap,  dorsal  scar.     (Farabeuf.) 

"The  joint  in  each  case  is  below,  or  distal  to,  the  prominence;  the 
metacarpophalangeal  joint  is  about  1/3  inch  below  the  knuckle; 
the  second  joint,  1/6  inch  below  the  knuckle;  the  terminal  joint  1/12 
inch  beyond  the  knuckle. 

"In  the  distal  and  intcrphalangeal,  the  joint  is  concave  from  side  to 
side  and  presents  a  concavity  toward  the  finger  tips.  In  the  meta- 
carpophalangeal joint,  the  convexity  is  toward  the  finger  tip. 

"From  the  readiness  with  which  the  tendons  conduct  infection,  care 
should  be  taken  to  keep  even  so  small  an  amputation  as  that  of  a 
finger  strictly  sterile,  and  in  amputating  through  damaged  parts  the 
flaps  should  not  be  too  closely  united  with  sutures." 

It  is  a  rule  with  but  few  exceptions  to  save  as  much  of  the  finger  as 
possible,  and  it  will  almost  always  happen  in  removing  part  of  a  finger 
that  an  atypical  amputation  will  be  indicated.      Let  the  scar  fall  where 


652 


SOME   PRACTICAL  AMPUTATIONS. 


it  will,  making  a  dorsal  or  a  lateral  flap  if  necessary.  The  palmar 
flap  and  dorsal  scar  is  ideal,  but  rarely  attainable  (Fig.  482).  There 
are,  however,  surgeons  of  large  experience  who  insist  that  a  palmar 
flap  be  secured  even  at  the  cost  of  more  finger,  and  that  less  than  half  a 
phalanx  should  not  be  saved,  but  cut  back  to  the  joint  to  avoid  flexure. 
(See  Ir»ji  ries  to  the  Hand.) 

If  ?  iutal  phalanx  is  to  be  removed,  begin  by  pronating  the  hand, 
forcibly  flex  the  phalanx  and  divide  the  skin  one-half  inch  distal  to  the 


Fig.  483. — Atypical  amputation  of  a  finger,  the  bone  projecting  beyond 
the  skin.     Dorsal  incision.      (Veau.) 

knuckle;  this  incision  deepened  will  open  the  joint.  Divide  the  lateral 
ligaments.  The  edge  of  the  knife  is  carried  under  the  phalanx  and 
swept  downward,  grazing  the  bone  and  cutting  with  a  steady  sawing 
movement.  The  result  is  indicated  in  Fig.  482.  Do  not  cut  the  flap 
too  short,  a  common  mistake  with  the  inexperienced. 


AN  ATYPICAL  AMPUTATION. 

Suppose  a  finger  to  have  been  sawed  off.  The  bone  projects  be- 
yond the  retracted  skin.  It  is  not  possible  to  fashion  a  flap  without 
removing  some  bone. 


\  I  \  PICAL     I  |\,,|   |.:     WH'I    I  \  ||i  >N. 


653 


Local  anesthesia  (Figs.  8  and  9).  Circular  constriction  al  the  base 
will  control  bleeding  ami  prevenl  rapid  absorption  of  tin-  solution. 
Begin  by  making  a  dorsal  linear  incision  an  inch  long  down  to  the 
bone  (Fig.  483). 

I  ,iberate  the  whole  circumferem  e  of  the  bone  one-third  inch  up,  either 

with  a  rugine  or  a  bistoury  (Fig.  484),  and  at  thai  level  divide  the  hone 
with  hone  forceps  (Fig.  485).  Employ  two  or  three  sutures  with 
drainage  if  there  is  much  chance  oi  infection  (Fig.  486). 


PlG.  484. — Liberating  the  bone.     (Vcau.)       Fig.  485. — Section  of  the  bone.     (Veau.) 

If  the  dorsal  linear  incision  opens  into  a  joint,  the  section  may  be 
made  there — disarticulate. 

Divide  first  the  dorsal  ligament,  then  the  lateral  ligament  to  the  left, 
and  as  the  phalanx  is  twisted  toward  the  left,  divide  the  lateral  liga- 
ment to  the  right.  Suture  as  before.  It  may  be  necessary  to  slice  on' 
the  head  of  the  remaining  portion  of  the  digit  if  it  is  too  prominent. 


TYPICAL  AMPUTATION  OF  THE  WHOLE  FINGER. 

General  anesthesia  is  usually  necessary.  The  method  of  procedure 
is  different  for  the  middle  and  ring  fingers,  the  index  and  little 
fingers,  and  the  thumb. 


654 


SOME   PRACTICAL  AMPUTATIONS. 


(I)  The  Middle  and  Ring  Fingers.— Locate  the  articular  line  by 
making  traction  on  the  finger  with  one  hand  and  palpating  each  side 
of  the  joint  with  the  index  finger  and  thumb  of  the  other  hand. 


Fig.  486. — Atypical  amputation:     Suture  and  drainage.     (Veau.) 


Fig.  487. — Typical  amputation  of  middle  finger:     Primary  incision  directed 
to  the  right.     (Veau.) 

Begin  the  incision  at  the  upper  level  of  the  joint;  carry  it  obliquely 
downward  and  forward  between  the  fingers  so  that  it  reaches  the 
palmar  surface  at  the  right,  a  little  below  the  crease  (Fig.  487). 


win   I  \  I  [ON    OF    nil'.    MIDDLE    PING1  R. 


655 


Lift  up  the  band  so  that  you  face  the  palm  and  cut  transversely  to 
the  left  (Fig.  488).  Now  lower  the  hand  and  complete  the  incision, 
bringing  it  obliquely  upward  and  backward  to  the  knuckle,  the  starting- 

point  (Fig.  489). 

Having  outlined  the  incision  in  this  manner,  repeat  the  movement, 
cutting  to  the  bone.     Retract  the  Bap,  exposing  the  articulation 


Fig.  488. — Amputation  of  the  middle  finger:     Lifting  the  hand  while 
making  the  transverse,  palmar  incision,     (veau.) 

Disarticulate.  Pull  on  the  linger  to  separate  the  joint  surfaces, 
which  helps  to  locate  the  joint  line.  Hold  the  bistoury  vertically, 
and  with  its  point  divide  the  lateral  ligament  to  the  left,  then  the 
dorsal  ligament  (Fig.  490),  then  the  ligaments  to  the  right,  at  the  same 
time  1  lending  the  finger  to  the  right. 

Tic  the  digital  arteries,  usually  one  on  each  side,  and  suture  (Fig.  491). 

(II)  Index  and  Little  Fingers. — In  these  two  instances,  the  aim 


656 


SOME   PRACTICAL  AMPUTATIONS. 


is  to  carry  the  scar  toward  the  dorsum  and  the  axis  of  the  hand.     In 
the  case  of  the  index,  it  falls  toward  the  ulnar  side;  in  the  case  of  the 


FtG.  489. — Amputation  of  the  middle  finger:     Completing  the  skin 
incision.      {Veau.) 


Fig.  490. — Amputation  of  the  middle  finger:     Traction  en  the  finger  while  the  bistoury- 
cuts  first  the  left  and  then  the  dorsal  ligaments.     (Veau.) 

little  finger,  toward  the  radial  side.     The  scar  is,  then,  in  each  case, 
furthest  removed  from   pressure. 

The  flap  itself,  of  rounded  outline,  folds  over  on  an  axis  passing 


AMPUTATION    OP    THE    I  I  I  I  I  I      FINGER. 


657 


obliquely  through  the  joint  cavity  and  approximates  the  adjoining 
lager. 

In  the  case  of  the  little  finger,  begin  the  incision  just  below  the  joint 
line  on  the  ulnar  side  of  the  extensor  tendon,  and  carry  it  obliquely 
downward  and  forward  and  then  across  the  palmar  surface,  inscribing 


Fig.  J91. — Amputation  of  the  middle  finger  completed.     (Vcati.) 

a  regular  semicircle  which  ends  at  the  free  border  of  the  web  between 
the  little  and  ring  fingers.  Complete  the  incision  by  cutting  from  this 
point  to  the  starling-point,  inscribing  a  semicircle  with  its  concavity 
toward  the  web.  Follow  this  same  track  again,  cutting  to  the  bone. 
Denude  the  bone  completely  (Fig.  492).  You  will  observe  that  the  ex- 
tensor tendon  is  difficult  to  divide  and  requires  especial  attention. 
Disarticulate.  Pull  on  the  digit  to  expose  the  joint  line  and  divide 
42 


658 


SOME   PRACTICAL  AMPUTATIONS. 


Fig.  492. — Amputation  of  the  little  finger- 
Flaps  completed.     (Veau.) 


Fig.  493. — Amputation  of  the  little  finger: 
Disarticulation,  cutting  from  left  to  right. 
(Veau.) 


Fig.  494.— Amputation  of  the  little 
{vfJu)         P     aft6r     disarticulation. 


Fig.  495. — Amputation  of  the  little 
finger:  flap  sutured.  The  line  of  union 
lies  toward  the  axis  of  the  hand  on  the 
dorsum.      (Veau.) 


AMI'I    IVi'lON     <>l      mi      imikx    FINGER. 


659 


the  lateral  ligaments  to  the  left  and  then  the  dorsal,  facilitated  by 
slight  flexion. 

Next,  rotate  the  finger  to  the  left  and  divide  the  lateral  ligaments  to 
the  right.  The  joint  is  completely  opened  and  the  rest  is  easy  (Fig. 
493).  The  appearance  of  the  flap  is  indicated  in  Fig.  494.  Employ 
three  or  four  interrupted  sutures  (Fig.  495). 


Fig.    496. — Amputation    of    index; 
showing  form  of  flap.     (Veau.) 


Fig.  497. — Amputation  of  index  and  little 
fingers  completed.     (Veau.) 


The  removal  of  the  index  finger  is  conducted  along  the  same  lines. 

The  first  semicircular  incision  is  carried  around  the  radial  side  and 
completed  by  a  second,  following  the  web  of  the  finger.  The  appear- 
ance of  the  flap  is  indicated  in  Fig.  496,  and  the  final  result  in  Fig.  497. 

If  the  patient  is  a  laborer,  it  is  necessary  to  render  the  hand  as  useful 


66o 


SOME   PRACTICAL  AMPUTATIONS. 


as  possible,  nor  must  the  cosmetic  effect  be  neglected.     It  is  neces-  ij 
sary  to  reduce  the  size  of  the  heads  of  the  metacarpal  bones. 

The  head  of  the  metacarpal  bone  of  the  index  is  best  reduced  by  an ' 
oblique  section  of  the  radial  side;  of  the  little  finger,  the  ulnar  side ; ; ; 
of  the  ring  finger,  by  transverse  section  (Fig.  498).  With  regard  to  the  j 
middle  finger,  the  head  of  its  metacarpus  should  not  be  removed:; 
unless  shapeliness  rather  than  strength  is  desired  (see  page  99). 


Fig.  498. — Lines  of  section  of  the  metacarpal  heads.      (Veau.) 


ATYPICAL  AMPUTATION  OF  THE  ENTIRE  FINGER. 

In  the  case  of  the  ring  or  middle  finger  mashed  off  near  the  meta- 
carpo-phalangeal  joint,  it  is  useless  to  try  to  save  the  stump,  as  its 
presence  will  be  an  actual  hindrance  to  the  other  fingers. 

Disarticulate.  Make  a  dorsal  incision  (Fig.  499),  extending  a 
centimeter  above  the  metacarpal  head.  Raising  the  finger  and  cutting 
from  left  to  right,  carry  the  incision  around  the  base  near  the  limit  of 
the  sound  tissue  (Fig.  500). 

Denude  the  bone,  exposing  well  the  metacarpal  head  and  hold  the 


AMPUTATIONS    OF    THE    Till   ML. 


66l 


flaps  well  back  out  of  the  way.  Divide  the  tendons  in  the  manner  al- 
ready indicated  for  the  amputation  of  the  finger  (Fig.  501).  Steady 
the  head  of  the  bone  and  pinch  off  with  a  bone  forceps  (Fig.  502). 

(Ill)  The  Thumb.— The  thumb  must  be  treated  with  the  utmost 
conservatism.  The  smallest  part  must  never  be  removed  unneces- 
sarily, as  it  is  almost  as  useful  as  the  rest  of  the  fingers  together, 


Fig.  499. — Crush  of  ring  finger  requiring  atypical  amputation.     Dorsal  incision  to 
expose  articulation.     (Lejars.) 


and  nearly  always  after  a  traumatism,  it  is  best  to  do  an  atypical 
amputation. 

In  the  typical  amputation,  employ  a  palmar  flap.  Begin  on  the 
dorsal  surface  just  below  the  articular  line  and  incise  to  the  right, 
reaching  the  edge  of  the  palmar  surface  just  above  the  interphalangeal 
crease. 

Now  go  back  to  the  starting-point  and  make  an  incision  to  the  left 


662 


SOME   PRACTICAL  AMPUTATIONS. 


similar  to  the  first,  and  complete  it  by  a  transverse  incision  joining  the 
first.     The  "U  "-shape  is  indicated  (Fig.  503). 

Repeat  the  incision,  cutting  to  the  bone,  and  dissect  up  the  flap. 
Strip  back  all  the  soft  parts  down  to  the  joint,  while  an  assistant  holds 
the  thumb. 

Disarticulate.     Take  hold  of  the  thumb  again  and  direct  the  as- 


Fig.  500. — Atypical  amputation  of  the  entire  finger:     Anterior  circular  incision.    (Lejars.) 

sistant  to  retract  the  flaps.  Make  strong  traction  and  cut  the  liga- 
ments to  the  left,  above,  and  then  to  the  right,  twisting  the  thumb  to 
make  them  tense.     Suture. 


AMPUTATION  OF  A  FINGER  AND  ITS  METACARPAL. 

Typical  amputation  (infrequent) : 

(1)  Middle  and  Ring  Fingers. — Begin  the  incision  over  the  carpo- 
metacarpal line  (on  the  line  drawn  between  the  bases  of  the  meta- 
carpals of  the  thumb,  and  little  finger)  and  descend  along  the  bone; 


SO. UK     TU  \i    I  [CAL    AMI'!    I  \  [IONS. 


663 


Fig.  501.— Atypical  amputation  of  the  entire  finper:     Disarticulation.     (Lejars.) 


Fig.  502. — Atypical  amputation  of  the  entire  finger:     Resection  of  the  head 
of  the  metacarpus.     (Lejars.) 


664 


SOME   PRACTICAL  AMPUTATIONS. 


follow  the  web,  cross  the  palmar  surface,  and  ascend  to  the  starting- 
point  (Fig.  504). 

Denude.  This  is  sometimes  difficult.  Dividing  all  the  tissues 
around  the  head  of  the  metacarpal,  work  up  and  toward  the  wrist, 
remembering  particularly  that  the  deep  palmar  arch  crosses  the 
middle  of  the  bone  and  is  in  touch  with  it.     It  must  not  be  injured. 

Disarticulate  by  dividing  the  bone  at  its  base  with  a  bone  forceps. 

(2)  The  Index  and  Little  Fingers. — The  procedure  is  the  same  as 
before  except  that  the  incision  on  the  side  opposite  the  axis  of  the  hand 


Fig.    503- — Line  of  incision  for  amputa- 
tion of  thumb.      {Farabeuf.) 


Fig.  504. — Lines  of  incision  for  remov- 
ing index  and  ring  fingers  and  their  cor- 
responding metacarpals.     (Veau.) 


extends  below  the  level  of  the  web,  in  order  that  on  that  side  the  flap 
may  be  longer  so  that  the  scar  will  fall  away  from  the  margin  of  the 
hand. 

(3)  The  metacarpal  of  the  thumb  may  be  regarded  as  a  finger; 
make  the  same  sort  of  racket  incision.  Save  all  of  the  metacarpal 
possible  (Figs.  505,  506,  507). 

Atypical  Amputation  of  the  Hand. — (Traumatism  of  the  meta- 
carpals) (Fig.  508). 

It  is  often  inadvisable  to  amputate  at  once,  for  parts  that  seem  de- 
vitalized may  survive. 


AM  IM    I  \  I  |c>\     OP     Mil      II  \M'- 


665 


Secure  hemostasis  and  cany  out  a  most  rigorous  disinfection, 
suture  with  ample  drainage  and  await  the  course  of  events;  the  limits  of 
viable  tissue  tan  soon  be  determined.  Amputate  before  gangrene  sets 
in.  Rather,  as  Lejars  says,  you  do  aol  amputate,  but  trim  up.  It  is 
the  rule  to  remove  the  projecting  bone  without  any  regard  to  a  typical 
amputation. 


PlG.  505. — Crushing  injury  destroy- 
ing thumb.  Part  of  its  metacarpal  to 
be  saved.      (Lejars.) 


Fig.  506. — Denuding  metacarpus  preparatory 
to  its  section.     (Lejars?) 


Denude  the  bone  as  far  back  as  the  skin  flaps  demand  (Fig.  509). 
Use  bone  forceps  (Fig.  510).  Suture  loosely  with  ample  drainage 
(Fig.  511).  Apply  a  moist  dressing,  which  is  to  be  changed  daily;  and 
if  the  temperature  rises,  remove  the  sutures  and  give  the  hand  a  pro- 
longed immersion  in  hot  normal  salt  solution  and  renew  the  dressings. 
Similar  amputation,  thumb  saved  (Fig.  512). 


666  SOME   PRACTICAL  AMPUTATIONS. 

AMPUTATION  OF  THE  FOREARM. 

Disarticulation  at  the  wrist  is  very  rarely  done  in  general  practice. 
If  a  tuberculosis  of  the  wrist  calls  for  intervention,  amputate  the  fore- 
arm (Fig.  513). 

Following  traumatism,  do  an  atypical  amputation,  conserving  as 
much  as  possible  of  the  member. 


Fig.  507. — Atypical  amputation  of  the  thumb  complete;  part  of  metacarpus 
preserved.     Drainage.     (Lejars.) 

Typical  amputations  of  the  forearm  are  most  easily  performed  at  any 
level,  by  a  modified  circular  incision;  the  dissection  of  the  cuff  is  facili- 
tated by  two  lateral  vertical  incisions  if  at  the  level  of  the  section  the  mem- 
ber is  conical.  Determine  first  where  you  propose  to  divide  the  bone. 
The  section  of  the  skin  must  fall  some  distance  below  that  of  the  bone. 
The  section  of  the  bone  should  be  made  about  the  distance  equal  to  the 
diameter  of  the  limb  above  the  skin  section. 


SOME   PRACTICAL  AMPUTATIONS. 


667 


Fig.  508. — Injury  to  hand.     Useless  to  try  to  save  any  but  the  index  finger.     (Veau.) 


Fig.  509. — The  metacarpals  are  denuded  upward  for  an  inch ;  all  the  soft 
parts  saved.     (Veau.) 


668 


SOME   PRACTICAL  AMPUTATIONS. 


Circular  Incision.— Begin  by  dividing  the  skin  in  front  (Fig.  514), 
and  complete  the  circle  posteriorly  (Fig.  515).  Divide  nothing  but 
the  skin  and  fascia. 

Lateral  incisions  are  to  be  made  extending  upward  two  or  three 
fingers'  breadth  (Fig.  516). 

Transfix.  Direct  the  assistant  to  hold  the  hand  supinated  and 
flexed  to  relax  the  flexor  muscles,  while  the  point  of  the  knife  is  intro- 


FlG.  s  10. —Section  of  metacarpals  with  bone-cutting  forceps.      (Veau.) 

duced  laterally  at  the  upper  end  of  the  nearest  vertical  incision  (Fig. 
517).  Elevate  the  point  of  the  knife  as  it  approaches  the  bone  so  that 
it  grazes  over  the  bone.  Drop  the  point  into  the  interosseous  space 
and  elevate  again  as  it  comes  in  contact  with  the  second  bone.  When 
it  emerges  at  the  opposite  side  at  the  same  level,  the  knife  is  swept 
downward,  its  cutting  edge  held  close  to  the  bones,  and  the  tissues  are 
cleanly  divided  longitudinally  until  the  level  of  the  circular  skin  in- 


SOMi:     PRACTICAL    AMPir.MIoNS. 


669 


cision  is  reached,  when  the  blade  is  made  abruptly  t<>  cut  toward  the 
surface  (Fig.  518).     As  the  section  toward  the  surface  is  made,  the 

assistant  should  extend  the  hand  slightly,  the  tense  tendons  being  more 
easily  divided. 

Pass  the  blade  posteriorly  in  the  same  manner,  and  as  the  knife  cuts 


Fig.  si  i. — Amputation  completed.      {Vcau.) 


toward  the  surface  the  hand  should  be  flexed.  The  muscles  which 
fill  in  the  interosseous  space  as  well  as  those  which  are  closely  attached 
to  the  bones  are  yet  to  be  divided.  Fig.  519  indicates  the  manner 
in  which  this  is  accomplished.  The  interosseous  membrane  requires 
special  attention. 

Denude  the  bones  of  periosteum  from  below  upward  (Fig.  520). 


670 


SOME   PRACTICAL  AMPUTATIONS. 


Fig.  512.  —  Ampu- 
tation of  the  hand. 
Thumb  saved.    (Senn.) 


The  adjacent  surfaces  of  the  bones  are  especially 
difficult  to  denude,  but  take  the  time  for  it.  Pass 
a  sterile  compress  between  the  two  bones  and  one 
on  either  side  to  act  as  retractors  while  the  bones 
are  sawed. 

Saw  the  bones  at  the  level  of  the  periosteal 
flaps.  Notch  the  ulna  first,  then  completely  divide 
the  radius  and  finally  the  ulna. 

The  median  nerve  will  be  found  in  the  midst 
of  the  muscles  of  the  anterior  flap  and  the  ulnar 
internally,  the  posterior  interosseous  is  more  diffi- 
cult to  find  posteriorly.  Resect  them  high  enough 
to  escape  the  scar.     Draw  the  periosteal  flaps  over 

the  end  of  the  bones  and  if  desired,  they  may 

be  sutured  with  catgut.     Suture  the  skin  and 

muscle  flaps,  and,  if  necessary,  drain  (Fig.  521). 

AMPUTATION  AT  THE  ELBOW-JOINT. 

Make  a  circular  incision  three  inches  below 
the  joint,  involving  the  skin  and  fascia.  Turn 
back  the  cuff  to  the  joint.  Divide  the  muscles 
over  the  joint  line.  Divide  the  lateral  liga- 
ments. Open  the  outer  side  of  the  joint  first 
and,  directing  the  assistant  to  make  traction 
on  the  arm,  separate  the  ulna  and  divide  the 
triceps.  Tie  the  arteries,  resect  the  nerves, 
and  suture. 

AMPUTATION  OF  THE  ARM. 

Apply  an  Esmarch  tube  high  up  near  the 
axilla,  or  an  assistant  may  compress  the  artery 
in  the  upper  part  of  the  arm  or  behind  the 
clavicle. 

Stand  to  the  outer  side  of  the  arm.     Retract 
the  skin  with  the  left  hand  if  operating  on  the        fig.  513. -Amputation 
right  arm,  or  direct  the  assistant  to  retract  the     il&thT^rist.  T(S 


SOMK    PRACTICAL    AM  l'l  TATIONS. 


67I 


Fig.  514 — Amputation  of  the  forearm:     Beginning  the  circular  incision.     {Veau.) 


Fig.   sis. — Amputation  of  the  forearm:     Completing  the  circular  incision.     (Veau.) 


672 


SOME   PRACTICAL  AMPUTATIONS. 


skin  if  operating  on  the  left  arm.     The  skin  section  must  lie  about  one 
diameter  below  the  proposed  bone  section  (Fig.  522). 

Divide  the  tegument  and  fascia  anteriorly  first  and  then  posteriorly. 
When  dividing  internally,  remember  that  the  artery  is  quite  superficial. 
If  a  long  blade  is  used,  the  complete  incision  of  the  skin  may  be 
accomplished  by  a  single  circular  sweep;  the  hand  carrying  the  knife 
is  passed  under  the  limb  until  the  heel  of  the  knife  rests  on  the  top  of 
the  limb,  and  then  with  slight  sawing  movements,  the  knife  is  made  to 


Fig.  516. — Lateral  incisions.     (Veau.) 

encircle  the  arm,  dividing  the  skin  successively  above,  internally, 
below,  externally,  and  above  again,  reaching  the  starting-point.  It 
may  be  necessary  to  make  the  pass  a  second  time  to  divide  the  fascia. 

Retract  the  skin  freely;  it  may  be  necessary  to  free  the  fascial  at- 
tachments with  the  point  of  the  knife.  Do  not  "button-hole "  the  flap. 
The  adhesions  are  most  marked  internally  over  the  artery.  The 
divided  skin  retracts  about  one  and  one-half  inches  (Fig.  523). 

In  the  meantime  there  is  considerable  venous  hemorrhage. 

Divide  the  muscles  by  a  circular  sweep  at  the  level  of  the  retracted 


S0M1     PB  \«  l  n  M,    win   I  \  riONS. 


673 


Fig.  517. — Transfixion.     (Vcau.) 


I'ig.  518.     Completing  the  anterior  Hap,  cutting  outward  following  transfixion.     (Vraw.) 
43 


674  SOME    PRACTICAL   AMPUTATIONS. 

skin,  cutting  to  the  bone  (Fig.  525).  If  a  scalpel  is  used,  cut  internally 
last,  so  that  the  artery  is  last  divided.  Work  fast,  for  the  bleeding 
will  be  free. 

Divide  the  muscles  a  second  time,  for  the  first  section  finds  them 
retracting  unequally.  Divide  them  at  the  level  of  the  retracted  skin 
(Fig.  526).  Be  sure  that  all  the  soft  parts  are  divided.  Catch  up  the 
bleeding  points  and  then  denude  the  bone  for  an  inch  (Fig.  527). 

Retract  the  flaps  with  sterile  compresses  and  saw  the  bone  as  high  as 
the  flaps  will  permit. 


Fig.  si 9. — Lines  of  incision  to  complete  section  of  the  soft  parts.     (Farabeuf.) 

Begin  the  section  with  the  heel  of  the  saw  on  the  bone  steadied  by 
the  thumb;  take  care,  at  the  end,  not  to  sliver  the  bone. 

Tie  the  brachial  artery  and  then  the  veins  with  strong  catgut; 
finally  tie  all  of  the  smaller  vessels.  Suture  the  muscles  first  over  the 
end  of  the  bone,  and  then  suture  the  skin. 

AMPUTATION  AT  THE  SHOULDER-JOINT. 

Amputation  at  the  shoulder  may  be  performed  by  a  variety  of 
methods,  each  of  which  has  its  advantages  and  disadvantages.  The 
special  points  to  be  thought  of  in  making  the  operation  are  the  control 
of  hemorrhage,  good  drainage,  easy  disarticulation  and  a  good  stump. 
No  one  operation,  perhaps,  secures  all  of  these  principles  in  equal 
degree. 

Spence's  method  is  recommended  as  generally  serviceable. 

Recall  the  principal  landmarks  of  the  shoulder-joint,  the  acromion 
process,  the  coracoid,  the  tuberosities;  recall  the  attachments  of  the 
various  muscles;  and  the  relations  of  the  blood  vessels. 


W1IM    l.\l  |(>.\    AX    mi;    SIK  >l  1  I  >l  K. 


675 


The  patient  is  placed  with  his  shoulder  close  to  the  edge  of  the 

table,  with  shoulder  elevated,  and  face  turned  to  the  opposite  Side. 
The  operator  stands  to  the  outer  side. 

The  operator  aims  at  the  exposure  of  the  joint  and  disarticulation, 
and  finally  the  formation  of  an  axillary  flap. 

Incision. — (1)  Begin  just  in  front  of  the  coracoid  process  and  cut 
vertically  downward  to  the  lower  level  of  the  tendon  of  the  pectoralis 


Fig.  520. — Stripping  back  the  perios- 
teum with  the  rugine.     (Veau.) 


Fig.     521. — Amputation     complete.     Trans- 
verse drainage.     (Vcau.) 


major,  keeping  in  front  of  the  groove  between  the  pectoralis  major 
and  deltoid.  This  incision  should  reach  the  bone;  the  pectoralis 
major  tendon  is  divided.  The  bleeding  comes  from  the  humeral 
branches  of  the  acromio-thoracic  and  from  the  anterior  cicrumtlex. 
These  vessels  may  be  clamped. 

(2)  Next  carry  the  incision  outward  across  the  arm,  making  a  slight 


676 


SOME   PRACTICAL  AMPUTATIONS. 


curve,  convex  downward,  and  ending  at  the  axillary  border.     All  the 
structures  are  divided  to  the  bone.     The  deltoid  is  divided  just  above 
its  insertion  and  the  hemorrhage  comes  from  the  muscular  branches. 
The  next  step  consists  in  outlining  the  internal  flap  by  making  an 


Fig.  522. — Circular  section  of  the  skin.     (Veau.) 


oval  skin  incision,  which  extends  from  the  termination  of  the  first 
across  the  inner  surface  of  the  abducted  arm  to  the  end  of  the  vertical 
part  of  the  first  incision  (Fig.  527). 

The  third  step  consists  in  elevating  the  external  flap  which  contains 
the  deltoid.     It  is  easily  dissected  and  by  this  means  the  joint  is  ex- 


WIIM   I  \l  I  < » N    A  l     I  III     SHOT  LDER. 


67' 


posed.     The  posterior  circumflex  artery  must  not  lie  injured  and  is 
preserved  in  the  deltoid  flap. 
The  fourth  stage:     Disarticulate.     Begin   by  dividing  tin-   l>i<ep^ 

trillion  and  the  capsule  with  a  transverse  cut.  Rotate  the  arm  in- 
ward and  divide  Successively  the  tendons  of  the  teres  minor,  the  in- 
fraspinatus, tin-  SupraspinatUS;  rotate  the  arm  outward  and  divide  the 


Fig.  523. — Freeing  the  skin  flap.     (Veau.) 


tendon  of  the  subscapularis.     If  the  humerus  has  been  broken,  rotate 
the  head  by  means  of  a  bone  forceps. 

Dislocate  the  head,  divide  the  capsule  behind  and  push  the  head  up 
to  the  level  of  the  acromion;  drawing  the  head  outward,  slip  the  knife 
behind  the  head  and  prepare  to  complete  the  section  of  the  soft  parts, 
ll  the  axillary  has  not  been  previously  ligated,  the  assistant  grasps  the 


678 


SOME   PRACTICAL  AMPUTATIONS. 


upper  part  of  the  flap  about  to  be  divided  and  his  hands  follow  the 
knife  downward  ready  to  compress  the  artery  as  soon  as  divided. 

The  knife  follows  the  bone  till  opposite  the  skin  incision  when  it 
cuts  directly  through  the  soft  parts  that  the  vessels  may  not  be  divided 
obliquely.     The  arm  is  now  completely  removed. 


Fig.  524. — First  circular  incision  of  the  soft  parts.      (Veau.) 


The  next  step  consists  in  ligating  the  vessels  and  in  trimming  the 
axillary  nerves  and  in  suturing  the  flaps  so  as  to  form  a  vertical  scar 
as  nearly  as  possible.     The  glenoid  fossa  may  be  curetted. 

For  the  control  of  hemorrhage,  Wyeth's  plan  of  constriction  may  be 
followed.  An  elastic  ligature  held  in  place  by  two  pins  passed  through 
the  soft  parts  before  and  behind  the  shoulder  compresses  the  axillary 
vessels. 


SCAPU1  0  in  Ml  R  \i    Wll'i   I  \l  [ON. 


679 


AMPUTATION  ABOVE  THE  SHOULDER. 

'This  operation,  bloody  and  often  fatal,  may  need  to  be  undertaken 
for  malignanl  disease  in  the  vicinity  «>i"  tin-  shoulder-joint  or  as  an 
emergency  in  the  case  of  crushing  injury  to  tin-  shoulder  <>r  of  gun- 
shol  wounds. 

The  procedure  as  defined  by  Berger  contemplates  the  resection  oi 
tlu-  middle  third  of  the  clavicle  and  Ligation  of  the  subclavian;  the 


Fig.  525. — Second  circular  incision  of  soft 
parts  at  level  of  retracted  skin.    (Veau.) 


Fig.  526. — Denuding  periosteum  with 
rugine.     (Veau.) 


formation  of  the  anteroinferior  and  a  postero-superior  flap;  and 
finally  the  division  of  the  muscles  connecting  the  scapula  with  the  trunk. 

The  operation  is  thus  described: 

Place  the  patient  on  his  hack  close  to  the  edge  of  the  table,  with  the 
shoulder  slightly  elevated.  Begin  the  incision  over  the  clavicle  at  the 
outer  border  of  the  sterno-mastoid,  and  follow  the  clavicle  outward  to 
the  acrominal  end,  cutting  to  the  bone.  Denude  the  middle  third  i)i 
its  periosteum  with  the  rugine,  and  divide  the  bone  at  the  junction  of 
the  inner  and  middle  thirds.  Elevate  the  bone  and  divide  again  at 
the  junction  of  the  middle  and  outer  third.     Separate  by  blunt  dis- 


68o 


SOME   PRACTICAL  AMPUTATIONS. 


section  the  fascias  overlying  the  subclavian  vessels  and  first  ligate 
the  artery  at  the  outer  border  of  the  first  rib  and  then  the  vein. 

Now  change  the  patient's  position:  the  shoulder  is  brought  over  the 
edge  of  the  table,  the  arm  abducted,  and  the  head  turned  to  the  oppo- 
site side. 

Form  the  antero-inferior  flap.  Begin  an  incision  at  the  middle  of 
the  first  and  carry  it  obliquely  downward  and  outward;  just  to  the 
outer  side  of  the  coracoid  process,  along  the  anterior  border  of  the 
deltoid,  to  the  axillary  border  and  thence  across  the  inner  surface  of 
the  arm  just  below  the  axillary  fold  and 
thence  down  the  axillary  border  of  the 
scapula.  Divide  the  pectorals  and  the  latis- 
simus  dorsi  close  to  their  insertions.  Resect 
the  nerves  of  brachial  plexus. 

From  the  poster o-superior  flap.  Begin  the 
incision  over  and  just  internal  to  the  acromio- 
clavicular joint  and  carry  it  downward  over 
the  spine  of  the  scapula  to  the  lower  angle 
of  the  scapula,  where  it  joins  the  preceding 
incision.  Dissect  the  flap  and  expose  the 
muscles.  Divide  first  the  trapezius  and  then 
with  heavy  scissors  divide  close  to  the  bone, 
the  muscles  attached  to  the  posterior  border, 
the  serratus  magnus,  the  rhomboideus  major 
and  minor,  and  the  levator  anguli  scapulae. 
Complete  the  hemostasis  and  drain  through 
button-holes  in  the  flaps  in  the  axilla  and  scapular  region.  Bandage 
firmly  so  as  to  obliterate  the  cavities. 


Pig 


527. — Spence's  amputa- 
tion.    (Moullin.) 

The  arm  falls  away. 


AMPUTATION  OF  THE  TOES. 

These  amputations  are  more  frequently  consequent  upon  trauma- 
tism; occasionally  for  deformity  or  other  painful  conditions. 

In  the  amputation  of  fingers,  as  much  as  possible  is  saved;  in  the 
amputation  of  toes,  the  whole  toe  is  nearly  always  removed.  In 
consequence,  these  amputations  are  usually  typical,  for  one  does  not 
so  much  need  to  concern  himself  with  the  conservation  of  tissue. 


win   i  \  i  io\    ui     i  ill     GR1  \  i     i"i 


68] 


In  the  case  of  total  ablation  of  the  finger,  a  pan  of  the  metacarpal 
lead  must  usually  be  removed  i"  enhance  function;  the  bead  of  the 
metatarsals  must  always  be  saved,  where  possible,  t<>  preserve  the  func- 
tions of  the  loot. 

The  position  of  the  cicatrix  demands  more  attention  in  the  case  <»t 

tin-  toes.  A  special  effort  must  be  made  to  leave  the  scar  farthest 
from  pressure;  that  is,  dorsal  and  to  the  inner  side  with  reference  t<» 
the  axis  of  the  foot. 

Local  anesthesia  is  often  sufficient,  forming  an  anesthetic  ring  around 
tin'  entire  toe,  involving  the  skin.  The  injection  may  need  to  be  renewed 
for  the  deeper  tissues;  and  before  disarticulation,  inject  the  joint. 

AMPUTATION  OF  THE  GREAT  TOE. 

In  amputation  of  the  great  toe,  the  flap  resembles  that  of  the  index 
finger  and  the  scar  adjoins  the  base  of  the  second  toe. 

Begin   by  locating  the  joint  line.     The   incision   commences  just 


1 


PlG.  528. — Lines  of  incision  for  am- 
putation of  big  toe.      (Farabcu}.) 


Fig.  529. — Amputation  of  big 
toe  completed.     (Farabeuf .) 


Fig.  530. 


below  this,  and  over  the  tibial  border  of  the  extensor  tendon,  and 
extends  with  a  slight  outward  convexity,  downward  and  forward  to 
the  interphalangeal  crease  on  the  plantar  surface  and  across  the  palmar 
surface  obliquely,  ending  at  the  web. 

Begin  on  the  dorsum  again  at  the  original  starting-point  and  with  a 
slightly  curved  incision,  join  the  ends  of  the  first  (Fig.  528). 


682 


SOME   PRACTICAL  AMPUTATIONS. 


Dissect  the  flap,  keeping  close  to  the  bone,  so  that  all  the  soft  parts 
shall  be  preserved  in  the  flap.  Divide  the  flexor  tendon — sometimes 
rather  difficult. 

Disarticulate.  Divide,  first,  the  lateral  ligaments  to  your  left,  then 
the  dorsal,  and  finally  those  at  your  right.  Divide  the  plantar  liga- 
ments, twisting  the  toe,  as  in  the  case  of  the  finger.  Employ  drainage; 
pull  the  flap  into  position  and  suture.  The  shape  of  the  flap  and  the 
position  it  assumes  are  represented  in  Figs.  529  and  530. 

AMPUTATION  OF  THE  LITTLE  TOE. 
Incision. — Begin  at  the  inner  end  of  the  joint  line  and  cut  obliquely 
downward  and  outward,  meeting  the  plantar  surface  at  the  joint  line 
below,  and  then  backward  and  inward  toward  the  web  (Fig.  531). 


Fig.  531.  _         Fig.  532.  Fig.  533. 

Amputation  of  the  little  toe.      (Farabeuf.) 

In  this  manner  a  convex  flap  is  formed  (Fig.  532).  Dissect  the  flap, 
preserving  in  it  all  the  soft  parts.     Expose  the  joint  line. 

Disarticulate.  Making  vigorous  traction  on  the  toe,  divide  in  reg- 
ular order  the  lateral,  the  dorsal,  the  lateral  (to  your  right),  and  plantar 
ligaments. 

Drain  from  the  upper  part  of  the  incision  and  suture.  The  position 
of  the  cicatrix  is  represented  in  Fig.  533. 

AMPUTATION  OF  ONE  OF  THE  MEDIAN  TOES. 
Incision. — The  line  of  the  joint  having  been  determined,  begin  just 
above  it  on  the  dorsum,  incising  forward  and  downward  to  just  below 


WIIM    I'AIION     Ml      K.I      \\  Mil     [TS     Ml    I  \T\KSrS. 


683 


the  web,  crossing  tin-  palmar  surface  and  bach  to  the  starting  point, 
Completing  the  racke!    (Fig.   534).     Remember  thai   the   metatarso 
phalangeal  joint  is  considerably  above  the  line  of  the  web.     Denude 
mil  divide  the  flexor  tendon. 

Disarticulate   in   the   manner  already  described    for  the  other  toes. 
Drain  from  the  upper  end  of  the  in<  ision  and  suture  (Fig.  535). 


Fig.  534. — Line  of  incision  for 
amputation  of  toe.     (Veau.) 


Fig.  535. — Suture  and  drainage 
after  amputation.     (Veau.) 


AMPUTATION  OF  A  TOE  WITH  PART  OF  ITS 
METATARSUS. 

This  amputation  presents  some  difficulties  in  dissecting  the  flaps, 
)ecause  of  the  palmar  projection  of  the  head  of  the  metatarsal. 

The  incision  is  racket-shaped,  as  in  amputation  of  the  toe,  but  it 
>egins  higher  up,  above  the  level  of  the  diseased  bone,  and  runs  down 
o  the  web,  across  the  palmar  surface  and  back  to  the  starting-point, 
.s  represented  in  Fig.  536.  To  dissect  the  Haps  for  the  middle  toes, 
lenude  the  dorsum  of  the  metatarsus  and  divide  it  with  the  bone  for- 
eps,  and  lifting  upon  the  divided  end,  dissect  forward  along  the  pal- 
nar  surface. 

The  metatarsus  of  the  little  and  great  toes  may  be  sawed.     In 


684  SOME   PRACTICAL  AMPUTATIONS. 

forming  the  flap  for  the  great  toe  and  its  metatarsus  (Fig.  537)  doil 
forget  to  remove  the  sesamoid.  Drain  as  in  amputation  of  the  tot, 
and  suture. 


Fig.  536. — Lines  of  incision  for  removal  of  toes  with  head  of 
corresponding  metatarsals.     (Veau.) 


FlG.  53  7. — Amputation  of  big  toe  with  head  of  metatarsal.      (Farabeuf.) 

AMPUTATION  OF  A  PART  OF  THE  FOOT. 

As  in  the  case  of  the  hand,  the  rule  is  to  conserve  as  much  as  possibl' 
of  the  foot  with  this  proviso,  that  a  painful  mass  of  scar  tissue  dod 
not  form  in  the  stump  and  the  action  of  the  flexors  of  the  foot  i 
retained. 

In  the  case  of  traumatism  or  gangrene,  where  the  soft  parts  ar 


\i  \  I'll  \i     win  i  \  i  m\   oi    i  in     FOOT. 


685 


oore  involved  than  the  bone,  the  line  of  section  follows  the  healthy 

J  kin  and  the  hone  section  will  be  made  to  accommodate  itself  to  the 

kin  flaps. 

Atypical  Amputation.— 1i  the  case  is  one  of  tuberculosis,  the  bone  is 

acre  involved  than  the  skin,  and  one  may  determine  the  Upper  limit 


ig.  538. — Following  the  line  of  demarcation. 
Atypical  amputation.      (Veau.) 


Fig.  539. — Dividing  the  bones. 
(Veau.) 


f  the  diseased  hone  and  divide  it  there.  In  such  a  case,  one  may 
ishion  a  palmar  flap,  and  make  a  dorsal  scar — the  typical  amputa- 
on.  But,  as  Veau  says,  do  not  concern  yourself  with  the  formal 
perations,  such  as  a  Lisfranc  or  a  Chopart — excellent  exercises  on 
ic  cadaver — but  saw  the  hones  where  you  must,  to  remove  all  the 
risease. 


686 


SOME   PRACTICAL  AMPUTATIONS. 


In  the  case  of  gangrene  or  traumatism,  then,  divide  the  tissues  t 
the  bone,  along  the  line  of  demarcation. 

The  borders  of  the  palmar  and  dorsal  flaps  must  correspond  t 
the  borders  of  the  foot  (Fig.  538).     Once  the  soft  parts  are  dividec 


Fig.  540. — Suturing  extensor  tendons  to 
skin  flap.     (Veau.) 


Fig.  541. — Suture  and  drainage. 
(Veau.) 


they  should  be  retracted  by  dividing  their  attachments  close  to  the 
bone,  and  the  bones  are  divided  high  enough  for  the  flaps  to  come'; 
together  (Fig.  53 9). 

In  the  case  of  tuberculosis  make  a  transverse  incision  dorsally  anc 


[NCISION    I  i  iK'    1 1 1 1  \  i.    wii'i   fATION    OJ     I  H  I     P001 


687 


gbape  the  long  palmar  flap  by  transfixion  and  cutting  outward,  <>i-  by 
Cutting  from  without  inward  (Fig.  .S40). 

Suture  the  tendons  to  the  periosteum  or  fibrous  tissues,  f«  >r  it  the  tendo- 
;uhillis  is  left  unopposed  the  result  will  be  a  useless  stump.     Ri 
the  nerves  and  suture,  using  drainage  (Fig.  541). 

TOTAL  AMPUTATION  OF  THE  FOOT. 

In  total  amputation  of  the  foot,  the  exact  procedure  will  depend 
chiefly  upon  the  condition  of  the  os  calcis.  If  it  is  sound,  Pirogoff's 
Osteoplastic  amputation  is  indicated.  If  the  os  calcis  is  diseased, 
Symcs'  amputation  is  indicated  a  disarticulation  at  the  ankle-joint, 
with  erasion  of  the  malleoli.     But  one  cannot  always  determine  before- 


Fig.  542. — Line  of  incision /or  complete  amputation  of  foot,     (Vcau.) 

.land  the  state  of  the  os  calcis,  and  therefore  an  incision  should  be 
Blade  which  will  permit  either  procedure  after  the  os  calcis  has  been 
xa  mined. 

First  Incision.  The  first  incision  extends  across  the  sole  with  one 
aid  at  the  tip  of  the  external  malleolus  and  the  other  a  finger's  breadth 
•clow  the  tip  of  the  internal  malleolus.  (The  internal  malleolus  does 
lot  extend  c^nite  so  low  as  the  external)  (Fig.  542). 

An  assistant  elevates  the  limb;  you  seize  the  foot  with  the  left  hand 

md  make  this  plantar  incision  from  left  to  right;  that  is  to  say,  in  the 

ase  of  the  right  foot  begin  the  incision  at  the  end  of  the  outer  malleolus 

iind  terminate  it  a   finger's  breadth   below  the  internal.      In   the  case 

if  the  left  foot,  begin  at  the  internal  and  end  at  the  external  malleolus. 

Repeat  the  movement  several  times,  for  there  is  always  considerable 


SOME    PRACTICAL  AMPUTATIONS. 


difficulty  in  accomplishing  complete  section  of  the  tendons,  some 
of  which  are  oblique  to  the  line  of  incision  and  others  deep  and  im- 
bedded in  grooves. 

Second  Incision. — Connect  the  extremities  of  the  first  incision  by  a 
dorsal  incision,  which  should  be  slightly  convex  forward  toward  the 
toes.     This  line  crosses  over  the  head  of  the  astragalus.     The  foot 


Fig.  543. — Section  of  the  lateral  liga- 
ments.    {Veau.) 


Fig.  544. — Clearing  the  upper  and  internal 
surfaces  of  the  os  calcis.      {Veau.) 


should  be  lowered  and  the  cut  made  from  left  to  right.  Extension  of 
the  foot  will  facilitate  the  division  of  the  anterior  tendons  and  liga- 
ments. 

Now  distinguish  the  head  of  the  astragalus,  and  between  it  and  the 
articular  surface  of  the  malleolus  pass  the  point  of  the  knife  and  cut 
downward  (Fig.  543).  By  this  means,  the  lateral  ligaments  are 
divided. 

The  posterior  ligaments  are  divided  by  cutting  along  the  upper 
surface  of  the  os  calcis  (Fig.  544).     The  joint  is  now  freely  exposed 


ui-' ii :i  'i  i  's   win  i  \  i  tON.  689 

and  the  os  calcis  may  be  brought  ini<>  view  and  examined.     In  examin 
bag  the  outer  side,  dissei  1  back  the  soft  parts  fur  an  in<  h,  but  not  quite 
so  far  on  the  inner  side.    To  be  sure  of  the  condition  of  the  bone,  its 
substance  must  be  inspected. 
(A)  Suppose  the  Os  Calcis  is  Sound.     Grasp  die  foot  firmly  with 

the  left  hand,  depress  it  and  pull  upon  it  at  the  same  time,  while  the 
assistant  retracts  the  flaps,  which  have  been  loosed  from  the  sides  of 
the  hone. 

The  flaps  are  held  back  by  retractors  on  each  side,  which  are  slipped 

down  with  the  progress  of  the  saw,  the  assistant  bracing  his  thumbs 
against  the  heel. 
The  saw  is  started  in  the  upper  face  of  the   os  calcis,   a  finger's 


Fig.  545. — Section  of  the  os  calcis.     The  saw  directed  downward  and  forward.     The 
retractors  slipped  downward  as  the  saw  progresses.     (Fiirabcuj.) 


breadth  behind  the  astragalus  in  a  manner  to  take  off  a  slice  from 
above  downward  and  forward  (Fig.  545).  With  the  completion  of 
this  section,  the  foot  is  removed,  and  the  posterior  part  of  the  divided 
os  calcis  is  left  in  the  heel  flap. 

The  next  step  is  to  saw  off  the  malleoli.  Begin  by  completely  de- 
nuding these  processes  of  their  covering,  skin,  fascia  and  tendons. 
Carry  the  denudation  upward,  a  distance  of  two  fingers'  breadth  be- 
hind; just  above  the  level  of  the  articular  surface  of  the  tibia,  in  front. 
The  posterior  tendons  especially  are  sometimes  difficult  to  dislodge 
from  their  groove. 

The  line  of  section  being  thus  cleared,  the  heel  flap  is  held  well  up 
toward  the  calf,  out  of  the  way,  by  the  assistant,  who  also  supports  the 
leg  in  the  horizontal  position. 
1 1 


690  SOME   PRACTICAL  AMPUTATIONS. 

It  is  well  for  the  operator  to  steady  the  limb  by  seizing  one  of  the 
malleoli  with  a  bone-holding  forceps.  The  saw  enters  just  above  the 
articular  line  in  front,  and  emerges  a  full  finger's  breadth  above  that 
level  (Fig.  546).  If  the  section  is  not  carefully  made,  the  coaptation  of 
the  sawed  surface  of  the  os  calcis  to  that  of  the  tibia  may  be  imperfect. 

Complete  the  hemostasis,  bring  the  two  bone  surfaces  together,  and 
suture  the  anterior  tendons  to  the  fibrous  covering  of  the  under  surface 


Fig.  546. — Parts  removed  in  Pirogoff's  amputation  represented  in  dark.     (Veau.) 

of  the  os  calcis,  the  better  to  fix  this  stump  in  position.  If  it  is  fearec 
the  bone  will  slip,  one  or  two  bone  sutures  may  be  employed.  Sutui 
the  skin,  usually  employing  drainage. 

(B)  Suppose  the  Os  Calcis  is  Diseased. — In  case  the  os  calcis  is  dis 
eased,  it  must  be  entirely  removed,  instead  of  sawed. 

The  left  hand  strongly  flexes  the  foot,  until  the  posterior  end  of  the 
os  calcis  points  upward  (Fig.  547),  and  as  the  point  of  the  knife  dissects 
the  tissues  off  the  left  side,  the  foot  is  rotated  to  the  right,  and  when 
working  on  the  right  side,  rotated  to  the  left;  in  this  manner  theos  calcis 
is  finally  enucleated,  being  careful  to  follow  the  bone  closely  and  not  toj 
"button-hole"  the  flap. 


s\  \n    S    IMPUTATION. 


691 


Fig.  547. — Denudation  of  the  posterior  surface  of  the  os  calcis.      (Farabeuf.) 


Fig.  548. — Syme's  amputation  of  the  foot.     (Farabeuf.) 


692  SOME   PRACTICAL  AMPUTATIONS. 

Remember  the  principal  vessels  are  to  the  inner  side  and  are  to  be 
lifted  up  with  the  flap. 

Especial  care  is  required  when  the  attachment  of  the  tendo-achillis 
is  divided ;  the  bone  must  be  shaved,  for  it  is  here  practically  subcutane- 
ous, and  it  is  easy  to  puncture  the  flap.  You  may  expect  this  stage  to 
be  tedious. 

Finally  the  foot  will  be  removed  (Fig.  548). 

Now  denude  the  lower  end  of  the  bones  of  the  leg,  observing  that 


Fig.  549. — Suture  and  drainage.      (Veau.) 

the  tendons  in  front  are  held  down  by  their  fibrous  sheaths.  In  order 
to  facilitate  this  dissection,  sweep  the  point  of  the  knife  around  the 
bone,  keeping  it  in  close  contact  with  the  bone.  This  dissection  must  be 
carried  upward  for  an  inch  and  the  malleoli  will  be  completely  exposed. 

Steady  the  leg  with  a  bone-holding  forceps,  and  saw  the  bones  at 
the  level  of  the  cartilage.  Begin  by  notching  the  tibia,  then  com- 
plete the  section  of  the  external  malleolus  and  terminate  with  the 
section  of  the  tibia.     If  some  cartilage  remains,  it  may  be  scraped  off. 

Resect  the  nerves,  suture  and  drain  (Fig.  549). 


wiim   i.\  rn  in    01     mi     LEG. 


AMPUTATION  OF  THE   II  G 
The  leg  may  be  amputated  at  any  level.     Formerly,  when suppura- 

tion   was  the  rule,  and   the  Cicatrix   was  large,  adherent,  and  painful, 

prohibiting  the  use  of  artificial  limbs,  the  "  point  <>f  election  "  was  high 


Fie.  550. — Knee  Hexed  for 
"peg-leg."     (Veau.) 


1 '  *'V'„-Vf 


Fig.    551. — Artificial   limb 
applied.     (Veau.) 


Fig.  552. — Amputation  of 
leg.  Lines  of  section  of  soft 
parts  and  bone.     (Wwm.) 


up.  The  knee  was  flexed  and  the  patient  made  use  of  a  "peg-leg," 
the  weight  falling  on  the  patella  (Fig.  550). 

With  present  methods  the  scar  is  a  matter  of  less  concern  and  the 
aim  should  be  to  amputate  as  low  down  as  possible,  to  the  end  that  the 
muscles  may  be  preserved  to  render  efficient  an  artificial  limb  (Fig.  551), 

This   principle   is   true  only   within  certain    limits.     Amputations 


694 


SOME   PRACTICAL  AMPUTATIONS. 


just  above  the  ankle  never  furnish  a  good  stump  for  an  artificial  limb. 
It  is  better  to  amputate  at  the  junction  of  the  middle  and  lower  thirds. 

In  the  case  of  traumatism  and  gangrene,  then,  do  an  atypical  ampu- 
tation, preserving  carefully  the  sound  tissue  and  dividing  the  bone  to 
accommodate  the  skin  flap. 

If  the  bone  is  involved  to  a  greater  extent  than  the  skin,  as  in  tuber- 


Fig.   SS3- — Loosening  the  attachments  of 
the  flap  to  the  tibia.     (Veau.) 


Fig.  554. — Dissecting  up  the  muscles  with 
the  artery.     (Veau.) 


culosis,  a  typical  amputation  may  be  done.  If  the  stump  below  the 
knee  is  four  inches  long  it  can  manage  an  artificial  limb. 

There  are  numerous  methods  of  amputating  the  leg,  some  appro- 
priate to  one  level  and  some  to  another,  but  for  the  sake  of  simplicity 
but  one  need  be  described — one  which  may  be  used  with  fair  success 
in  any  part  of  the  leg.  In  any  case  avoid  redundancy  of  flap  if  an 
artificial  leg  is  to  be  worn. 

Incision. — Begin  with  a  circular  incision  of  the  skin  about  two  and 


win  i  \Ti<i\    \  i    mi     km  i   JOIN  I  695 

one  half  inches  below  the  level  <>i"  the  proposed  bone  section  (Fig.  552). 

This   incision    will   divide   the  skin   and    aponeurosis.      If   front,  <  art- 
fully separate  the  skin  from  the  tibial  cresl  (Fig.  553).     \'<  \i  <livi<l<- 
the  muscles  at  the  level  of  the  retrai  ted  skin.     Divide  the  muscles  com 
bletely,  but  make  the  incision  oblique  to  the  axis  of  the  limb,  so  that  the 
incision  reaches  tin-  bone  at  a  higher  level  than  at  the  surfa<  e  |  Fig.  554). 

To  he  certain  that  all  tin-  muscles  are  divided,  one  may  repass  the 
bistoury,  as  in  the  forearm  (Fig.  519).  Next 
denude  the  hones  with  the  rugine,  reaching 
ahow  the  level  at  which  the  hones  are  to  he 
sawed.  This  denudation  is  most  difficult  and 
tedious  behind,  on  account  of  the  fibrous  attach- 
ments of  various  muscles. 

The  interosseous  membrane  is  to  be  detached 
by  a  feu  vigorous  strokes  with  the  rugine  from 
below  upward.  Divide  it  at  the  level  of  the 
proposed  bone  section. 

Retract  the  flaps  with  three  gauze  compresses, 
one  passed  between  the  bones,  one  applied  in  FlG  sss._ Amputation 
front  and  one  behind;  all  to  be  held  firmly  by  the  Hj*e-  (iw""" 
assistant. 

Begin  Hie  sawing  by  notching  the  tibia,  then  completely  divide  the 
fibula  and  end  with  the  section  of  the  tibia.  Plane  off  the  projecting 
angle  of  the  anterior  border  of  the  tibia,  resect  the  nerves  and  ligate 
the  bleeding  points.  Be  sure  the  fibula  is  not  left  longer  than  the 
tibia  to  interfere  with  an  artificial  limb.  Drain,  suture  the  anterior 
muscular  flap  to  the  posterior,  and  suture  the  skin  (Fig.  555). 

AMPUTATION  THROUGH  THE  KNEE-JOINT. 

This  operation  should  be  done  in  preference  to  an  amputation  of 
the  thigh. 

"The  femoral  artery  having  been  controlled,  the  limb  supported 
over  the  edge  of  the  table  and  slightly  flexed,  the  surgeon  standing  on 
the  right  side  of  either  limb,  marks  out  two  broad  lateral  flaps  as 
follows:  his  left  thumb  and  index  finger  being  placed,  the  former  over 
the  center  of  the  head  of  the  tibia,  the  hitter  at  the  corresponding  point 


6g6 


SOME   PRACTICAL  AMPUTATIONS. 


behind,  opposite  the  center  of  the  joint,  he  marks  out  (in  the  case  of  the 
right  limb)  an  inner  flap  by  an  incision  which  commences  behind  at  the 
index  finger  and  runs  down  the  back  of  the  leg  for  three  and  one-half 
inches,  and  then  curves  up  to  the  thumb.  A  similar  flap  is  shaped 
on  the  outer  side. 

"The  inner  flap  must  be  slightly  larger,  in  view  of  the  large  side  of 
the  inner  condyles. 


Fig.  556. — Circular  incision  of  the  skin. 


"The  flaps  consist  of  skin  and  fascia.  When  they  have  been  raised 
to  the  level  of  the  articulation,  the  ligamentum  patellae  is  severed, 
allowing  the  patella  to  go  upward.  The  soft  parts  around  the  joint 
are  then  cut  through  with  a  circular  sweep  and  the  leg  removed.  In 
doing  this,  the  limb  being  flexed  to  relax  the  parts  and  facilitate 
opening  the  joint,  the  semicircular  cartilages  will  very  likely  be  found 
encircling  the  condyles  of  the  femur  and  are  to  be  left  in  situ  by  divid- 
ing the  coronary  ligaments  which  tie  them  to  the  tibia.  The  condyles 
should  always  be  saved  if  possible  for  they  favor  the  usefulness  of  an 


tONS    1\    Wll'l    I  \  I  l"\    "l     nil.    THIGH. 


'">: 


;irtiii(  ial  limb.     Resect  the  nerves,  ligate  the  vessels,  drain  and  suture." 
(Jacobson's  Operative  Surgery.) 

.WIN  TATK  >.\  <  IF  THE  THIGH. 

Determine  the  level  of  the  bone  section:  About  the  distance  of  one 
liameter  oi  the  limb  below  this  level,  describe  a  circular  incision, 
lividing  the  skin  and  fascia,  which  may  descend  a  little  further  behind 
than  in  front,  il  desired. 


Fig.  557. — Loosening  the  flap  after  a  circular  skin  section. 

The  patient's  legs  are  drawn  out  well  over  the  edge  of  the  table,  the 
well  limb  flexed  and  the  injured  one  held  by  an  assistant.  The  oper- 
ator stands  to  the  outside.  Another  assistant  encircles  the  thigh  above 
the  level  of  the  incision,  with  his  hands.  If  the  conventional  am- 
putating knife  is  used,  begin  (on  the  right  thigh)  by  passing  the  knife 
under  the  limb  and  with  its  heel  resting  upon  the  upper  surface,  bring 
it  in  a  circular  sweep  back  around  the  thigh,  dividing  successively 
the  integument  of  the  internal,  inferior  and  external  surfaces.  The 
position  of  the  hand  may  be  slightly  changed  and  the  incision  continued 
ptpover  the  anterior  surface;  or  that  may  be  divided  by  a  second 
movement  (Fig.  556). 


698  SOME   PRACTICAL  AMPUTATIONS. 

In  the  meantime,  the  left  hand  has  steadied  the  skin;  the  assistant 
now  retracts  it  while  its  fibrous  attachments  are  loosened  (Fig.  557) 
until  there  is  a  separation  of  at  least  three  fingers'  breadth.  At  the 
level  of  the  retracted  skin,  divide  the  muscles  as  the  skin  was  divided, 
aiming  to  reach  the  bone.  But  the  divided  muscles  do  not  equally  re- 
tract, and  a  second  circular  incision  of  the  muscles  at  the  level  of  the 
retracted  skin  is  necessary  to  insure  a  uniform  stump  (Fig.  558). 


oK '.  ¥UtjJ>c. 


Fig.  S58. — Circular  section  of  the  muscles  after  retraction  of  skin. 

Denude  the  femur  beyond  the  level  of  the  proposed  bone  section. 
Direct  the  assistant  to  retract  the  flap  with  two  lateral  compresses  or 
retractors. 

Saw  the  femur,  ligate  all  vessels  likely  to  bleed,  suture  the  muscles 
over  the  end  of  the  femur,  drain,  and  suture  the  skin. 

AMPUTATION  OF  THE  HIP-JOINT. 

"Primary  amputation  of  the  hip  comes  under  consideration  in  any 
extensive  crush  of  the  thigh  or  gunshot  injury,  but  offers  hardly  any 
change  while  the  primary  shock  exists. 


>i  w's  .wiimi  \i  [ON  AT  Tin.   mi'.  699 

"The  better  plan  is  to  try  and  check  the  hemorrhage,  clean  the 
wound  as  much  as  possible,  pack  with  gauze  and  wait.  The  patient 
laving  rallied  from  the  shock,  and  gangrene,  sloughing  and  uecrosis 
leing  imminent,  amputation  is  indicated  with  a  fair  prospei  t  of  saving 
life.  *  *  *  The  first  stc- j >  is  t<>  control  hemorrhage.  *  *  *  But  there  is 
one  method  safe  and  applicable  to  all  cases  and  especially  when  the 
surgeon  is  unaccustomed  to  the  operation,  and  that  is  to  divide  the 
common  femoral  vein  and  artery,  each  between  two  ligatures.  There- 
is  then  no  further  bleeding,  except  from  the  region  of  the  crucial 
anastomosis  behind,  the  vessels  forming  which  are  easily  picked  up 
and  divided." 

For  malum  of  the  Flaps. — "From  the  lower  end  of  the  longitudinal 
mcision  for  tying  the  vessels,  a  circular  incision  is  continued  around 
the  thigh,  the  skin  flaps  retracted  and  the  soft  parts  divided  as  ampu- 
tation of  the  thigh."  (Walsham's  Surgery.) 

Semi's  Bloodless  Amputation  at  the  Hip-joint. — First  incision:  with 
the  pelvis  resting  on  the  lower  edge  of  the  table,  make  a  straight  in- 
cision (beginning  about  three  inches  above  the  great  trochanter)  about 
eight  inches  in  length,  directly  over  the  center  of  the  great  trochanter, 
and  parallel  to  the  long  axis  of  the  limb.  When  the  knife  reaches  the 
great  trochanter,  its  point  should  be  kept  in  contact  with  the  bone 
the  whole  length  of  the  remaining  part  of  the  incision. 

The  margins  of  the  wound  are  now  retracted  and  any  spurting  ves- 
sels secured. 

The  trochanteric  muscular  attachments  are  now  severed  close  to 
the  bone  with  a  stout  scalpel.  The  cleaning  of  the  digital  fossa  and 
the  division  of  the  obturator  externus  tendon,  require  special  care. 
The  thigh  is  now  flexed,  strongly  abducted,  rotated  inward,  when 
the  capsular  ligament  is  divided  transversely  at  its  upper  and  posterior 
aspect.  The  remaining  portion  of  the  capsular  ligament  is  severed, 
while  the  thigh  is  brought  back  to  a  position  of  slight  flexion,  after 
which  it  is  rotated  outward  and,  if  possible,  the  ligamentum  teres  is  cut. 
If  this  cannot  be  done,  the  head  of  the  bone  is  forcibly  dislocated  upon 
the  dorsum  of  the  ilium  by  flexion,  adduction  and  rotation  of  the  thigh. 

The  trochanter  minor  and  upper  part  of  the  shaft  of  the  femur  are 
cleared  by  using  a  scalpel  and  periosteal  elevator  alternately.     At 


700 


SOME    PRACTICAL  AMPUTATIONS. 


the  completion  of  this  part  of  the  operation,  the  femur  is  in  a  position 
of  extreme  adduction  and  the  upper  portion  projects  some  distance 
from  the  wound. 

If  the  surgeon  has  kept  in  close  contact  with  the  bone  and  has  used 
the  knife  sparingly  and  the  periosteal  elevator  freely,  the  hemorrhage 
has  been  slight. 

Elastic  constriction  is  now  applied.  Bring  the  limb  down  in  a 
straight  line  with  the  body.  A  long  straight  hemostatic  forceps  is 
inserted  into  the  wound  behind  the  femur  and  on  a  level  with  the  tro- 


Fig.  559. — Elastic  constriction  completed  by  constricting  the  posterior  segment  of  the  thigh 
Flaps  formed,  including  all  the  tissues  down  to  the  muscles.      (Senn.) 


chanter  minor  when  in  a  normal  position.  The  instrument  is  then 
pushed  inward  and  downward  two  inches  below  the  ramus  of  the  is- 
chium and  just  behind  the  adductor  muscles.  As  soon  as  the  point 
can  be  felt  under  the  skin  in  this  location,  two-inch  incision  is  made 
through  the  skin,  through  which  the  instrument  is  made  to  emerge. 

After  enlarging  the  tunnel  made  in  the  soft  tissues  by  dilating  the 
branches  of  the  forceps,  a  piece  of  aseptic  rubber  tubing,  three  or 
four  feet  in  length,  is  grasped  in  the  middle  with  the  forceps  and  drawn 
along  the  tunnel  as  the  forceps  are  withdrawn,  whereupon  the  rubber 
tube  is  cut  in  two  where  it  was  held  by  the  forceps. 


senn's    \mipi  i  \  I  I"--    I  I    I  in    mi*.  701 

With  one  half  of  the  tube,  the  anterior  3egmen1  of  the  thigh  is 
■onstricted  sufficiently  firmly  to  intercept  l«>th  the  arterial  and  venous 
an  illation  1  ompletely. 

Before  the  constrii  tor  is  tied,  the  limli  should  be  held  in  the  vertical 


,6o. — Senn's  method  of  performing  bloodless  amputation  at  the  hip-joint:  Dislo- 
cation of  head  of  femur  and  upper  portion  of  shaft  through  straight  external  incision. 
Elastic  constrict<  rs  in  place;  the  anterior  one  tied. 

position  long  enough  to  render  it  practically  bloodless.  The  elastic 
constrictor  is  either  tied  or,  still  better,  held  with  a  forceps  at  the  point 
of  crossing. 

The  posterior  segment  of  the  thigh  is  constricted  by  the  remaining 
half  of  the  tube,  which  is  drawn  sufficiently  tight  behind;  the  ends  of 


702  SOME   PRACTICAL  AMPUTATIONS. 

the  tube  are  made  to  cross  each  other  and  are  brought  forward  and 
made  to  include  the  anterior  segment,  when  they  are  again  firmly 
drawn  and  tied,  or  otherwise  fastened  above  the  first  constrictor, 
furnishing  an  additional  security  against  hemorrhage  from  the  larger 
vessels  in  the  anterior  flap,  when  cut  during  the  amputation  (Fig.  559). 

After  the  principal  blood  vessels  have  been  tied,  the  posterior  con-. 
strictor  is  removed  and  additional  bleeding  points  are  secured  before 
the  anterior  constrictor  is  removed  (Fig.  560). 

Surface  compression  with  a  compress  wrung  out  of  hot,  normal  salt 
solution,  is  a  valuable  aid  in  minimizing  the  hemorrhage,  after  the 
removal  of  the  constrictors. 

"As  this  method  of  controlling  hemorrhage  does  not  require  the 
presence  of  a  skilled  assistant,  it  will  prove  of  especial  value  in  emer- 
gency cases.  The  operation  can  be  performed  with  the  instruments 
contained  in  every  pocket  case.  Should  an  elastic  tube  not  be  at 
hand,  the  constriction  can  be  made  in  a  satisfactory  manner  by  sub- 
stituting a  cord  made  of  sterile  gauze,  tightened  with  a  lever  of  some 
kind,  as  is  done  in  applying  the  ordinary  Spanish  windlass."  (Senn, 
Practical  Surgery.) 

The  amputation  is  completed  by  cutting  antero-posterior  flaps  as 
shown  in  Fig.  559. 


CHAPTER    XXIII. 

DILATATION  OF  THE  SPHINCTER  ANI ;  OPERATION 
FOR  PILES;  OPERATION  FOR  FISTULA. 

DILATATION. 

Temporary  paralysis  of  the  ana!  sphincter  is  the  preliminary  step 
to  mosl  of  the  interventions  on  the  rectum,  and  may  be  of  itself  suf- 
ficient for  the  cure  of  fissures. 

The  patient  should  be  purged  the  day  preceding  the  operation;  and 


Fig.  561. — Dilatation  of  the  rectum.     (Vcau.) 

the  rectum  should  be  washed  out  with  soap  and  water,  preliminary  to 
the  actual  operation. 

General  anesthesia  is  almost  indispensable  and  it  needs  to  be  pro- 
bund,  for  the  anal  reflex  is  one  of  the  last  to  yield.  Spinal  anesthesia 
.S  often  useful  in  anal  operations. 

In  the  absence  of  a  special  dilator,  begin  by  inserting  the  two  thumbs 

703 


7°4 


DILATATION   OF    THE    SPHINCTER  ANI. 


back  to  back,  and  bracing  the  fingers  against  the  outer  surface  of  the 
hips,  stretching  the  sphincter  by  rhythmic  movements  of  the  thumbs, 
gradually  increasing  the  force.  There  is  no  danger  of  overdilatation, 
so  continue  until  the  thumbs  are  in  contact  with  the  ischial  tuberosities 
(Fig.  561).  Drainage  is  indicated  in  simple  dilatation  for  fissure. 
Employ  either  one  large  or  two  or  three  small  tubes  well  wrapped 


Fig.  562. — Drainage  after  dilatation.     (Veau.) 

with  iodoform  gauze  soaked  in  cocainized  vaseline  (vaseline  thirty 
parts,  cocaine  one  part),  in  order  that  the  subsequent  pain  may  not 
be  so  severe  (Fig.  562).  The  tubes  may  be  removed  on  the  second; 
day  and  the  bowels  moved  on  the  third. 


OPERATION  FOR  HEMORRHOIDS. 

Most  cases  of  piles  are  curable  by  local  and  constitutional  treatment; 
however,  those  that  are  very  large,  bleeding  and  inflamed,  require  anil 
operation  for  their  removal  and  radical  cure. 

There  are  several  methods  of  procedure,  many  of  which  are  success- 
ful; none  dangerous  and  quite  within  the  scope  of  every  practitioner. 


<>l'l  l'\  riON    l  OB    I'll  I  s. 


f°5 


The  following  may  be  recommended  in  those  cases  in  which  the 
marginal  tumors  are  well  defined  but  do!  pedunculated: 

Begin  l>y  a  careful  cleansing  of  the  bowel  by  purgation  and  lavage. 
Tlmr  days  before  tin-  operation,  give  a  free  purge  and  prescribe  ;l 
■quid  diet.  Prescribe  an  enema  each  morning  and  evening  for  the 
next  two  days.  I  m  the  day  preceding  the  operation,  it  is  a  good  idea 
to  check  peristalsis  with  a  small  dose  of  opium. 

Employ  genera]  anesthesia.  Carefully  cleanse  the  peri-anal  region 
and  send,  the  rectum  with  soap  and  water.     Dilate  the  anus,  as  pre- 


FlG.    563. — Making    the    first 
incision.      (IVjii.) 


Fig.    564. — Passing   the   first 
suture.     (Wcjm.) 


viously  described;  and  when  the  dilatation  is  complete  the  anal  orifice 
will  be  everted  more  or  less,  presenting  a  ring  of  pile  tumors.  Fasten 
the  pile  tumor  with  a  forceps,  and  at  its  lower  end,  make  a  short  curved 
incision  (Fig.  563).  The  incision  involves  only  the  skin,  which  is  to  be 
Bosened  from  the  underlying  structures  by  a  little  blunt  dissection. 
Suture  this  part  of  the  skin  before  proceeding  further,  using  a  small 
curved  needle  armed  with  a  No.  2  catgut.  Tie  the  suture  moderately 
bight  and  leave  the  threads  long  for  a  landmark,  which  will  be  ap- 
preciated later  on.  Pass  two  or  three  sutures  in  this  manner,  depend- 
ing upon  the  length  of  the  incision  (Fig.  564). 
45 


706 


DILATATION    OF   THE    SPHINCTER  ANI. 


Again  prolong  the  incision  on  either  side  a  little  way  and  detach, 
by  blunt  dissection,  the  lips  of  the  wound  from  the  veins  beneath,  by 
which  means  a  sort  of  pedicle  is  formed  (Fig.  565).  This  pedicle  con- 
sists of  a  part  of  the  veins  which  are  to  be  ligated  and  excised. 


Fig.  565. — Freeing  the  veins  by  blunt  dis- 
j»    section.      (Veau.) 


Fig.   566. — Ligation  of  the  first  vascular 
pedicle.     {Veau.) 


Fig.  567.— Burying  the  pedicle  by  suture. 
(Veau.) 


Fig.  568. — Ligation  of  the  last  vascular 
pedicle.      (Veau.) 


Pass  a  ligature  around  a  part  of  the  veins  (Fig.  566)  and  tie.     Divide 
the  ligated  veins  to  the  outer  side  and  cut  the  ligatures  short. 

Now  pass  a  suture  so  as  to  enclose  and  cover  in  the  stump  (Fig.  567). 


OPERATION    I  OB    PILES.  707 

Again  prolong  the  original  incision  on  each  side  of  the  base  ol  the 
tumor  and  expose  more  of  1 1 1 « -  pedi<  le;  ligate,  ex<  ise  and  suture  as  be- 
fore, until  finally  the  upper  pole  of  the  tumor  is  rea<  bed,  and  the  last  of 
the  pedicle  tied  off  (Fig.  568). 

The  terminal  sutures  enclose  the  las!  stump  of  the  pedii  le  and  i  om 
plete  the  repair  of  the  incision  at  the  same  time  (Fig.  569). 

It  is  better  to  proceed  thus  from  In-low  upward  in  order  that  the 
Mood,  always  considerable,  will  flow  downward  and  mask  only  the 
field  already  sutured. 


Fig.  569. — Applying  the  last 
suture,     (veau.) 


PlG.    570. — Treatment    of   ulcerated 
piles  by  cautery.     {Veau.) 


The  line  of  incision  must  follow  closely  the  base  of  the  tumor,  for 
if  the  edges  of  the  wound  are  too  widely  separated,  the  strain  may 
cause  the  sutures  to  tear  out. 

If  the  whole  of  the  anal  circumference  is  involved,  it  is  necessary  to 
treat  in  the  manner  described  the  two  sides  only. 

Do  not  disturb  the  anterior  and  posterior  poles  of  the  anal  border, 
although,  if  necessary,  those  points  may  be  touched  up  with  the  thermo- 
cautery. 

Place  drainage-tubes  wrapped  with  iodoform  gauze  saturated  in 
vaseline,  as  described  under  the  head  of  Dilatation  of  the  Sphincter. 

The  subsequent  pain  is  always  severe  and  will  require  a  hypodermic 
injection  of  morphia.     Retention  of  urine  is  often  present.      The  ex- 


708 


DILATATION    OF    THE    SPHINCTER  ANI. 


ternal  dressings  should  be  changed  daily  and  liquid  diet  maintained  for 
five  or  six  days  and  the  bowels  kept  under  restraint.  Do  not  be  con- 
cerned with  the  swelling. 

On  the  sixth  day,  remove  the  drainage-tube;  on  the  seventh,  open  the 
bowels  with  castor  oil,  and  instruct  the  patient  to  cleanse  carefully  the 
anal  region  after  each  movement. 

The  sutures  will  be  absorbed  and  if  none  give  way  too  soon,  the 


Fig.  5 7 1- — Laying  open  the  track  of  fistula  on  the  grooved-director.     (Veau.) 


healing  will  be  complete  in  about  two  weeks;  otherwise  there  may  be 
a  raw  surface  which  will  need  to  be  dressed  a  little  longer. 

In  certain  cases  there  is  no  well-defined  tumor,  but  the  surface  is 
ulcerated,  infected  and  exceedingly  painful,  and  is  unaffected  by  patient 
local  treatment. 

In  such  a  case,  the  thermo-cautery  will  probably  give  the  best  results. 
For  .one  or  two  days  the  patient  is  kept  in  bed  and  a  moist  dressing 
applied  which  will  diminish  the  swelling. 

Employ  general  anesthesia,  cleanse  and  dilate  the  anus.  The  ther- 
mo-cautery is  heated  to  a  dull  red.     Pressed  into  the  tumor,  it  loses  its 


CAUTERIZATION    01     ULCERATED  PILES. 


709 


glow  (Fig.  570).  Reheat  it  and  reapply  a  short  distan<  e  from  the  poinl 
of  appli<  ation,  and  in  this  manner  pro<  eed  until  the  pile  has  been  well 
punctured.  It  is  nol  necessary  to  puncture  deeply.  Apply  drainage 
and  a  moist  dressing.  The  subsequent  pain  is  always  severe  and  must 
be  <  ontrolled  by  a  hypodermic  of  morphia.  There  may  be  retention  oi 
urine  requiring  relief  by  catheterization.     The  dressing  must  l>e  re- 


PlG.  =,72. — Cauterization  of  the  diverticula  of  the  fistula.     (Vcau.) 


Dewed  twice  daily.  The  eschar  will  drop  off  between  the  fourth  and 
eighth  day,  and  the  bowels  should  be  moved  about  the  eighth  day. 
The  cure  will  be  complete  in  about  a  month. 

OPERATION    FOR  ANAL   FISTULA. 

A  grooved  director  is  passed  through  the  fistulous  tract  and  emerg- 
ing in  the  rectum,  its  point  is  caught  by  the  finger  in  the  rectum  and 
brought  outside  the  anus.     The  whole  length  of  the  tract  is  laid  open 

(Fig-  570- 

The  diseased  tissues  arc  then  curetted  or  touched  with  the  cautery 
(Fig.  572).     Pack  with  gauze  until  repair  by  granulation  is  complete. 


CHAPTER  XXIV. 

PHIMOSIS;  PARAPHIMOSIS;  CIRCUMCISION; 
HYDROCELE;  CASTRATION. 

PHIMOSIS. 

Phimosis  may  be  congenital  or  acquired,  though  it  is  much  more 
frequently  the  former.  There  is  usually  present  one  or  both  of  two 
conditions:  a  redundant  prepuce  with  contracted  orifice;  or  a  frenum 
so  short  as  not  to  permit  retraction  without  marked  bowing  of  the 
organ. 

The  disturbances  produced  by  congenital  phimosis  are  due  either  to 
mechanical  interference  or  reflex  irritability,  although,  of  course,  many 
cases  of  phimosis  seem  to  give  rise  to  the  symptoms.  The  mechanical 
interference  may  lead  to  infection,  balanitis,  or  even  urethritis,  or  to 
straining  which  may  be  the  origin  of  an  inguinal  or  umbilical  hernia; 
the  straining  may  also  produce  prolapsus  ani  or  hydrocele  by  pres- 
sure on  the  spermatic  vessels. 

The  reflex  symptoms,  often  due  perhaps  to  the  adhesions  of  the 
prepuce  to  the  glans,  are  numerous  and  varied,  the  most  common  be- 
ing disturbances  of  micturition,  erethrism,  and  functional  nervous 
derangements. 

Every  case  of  phimosis,  therefore,  should  receive  attention  in  in- 
fancy, and  in  general  the  only  treatment  worth  while  is  circumcision. 

The  acquired  phimosis  of  adult  life,  most  often  due  to  acute  infect- 
ive inflammations,  is  usually  to  be  relieved  by  antiseptic  washes  and 
treatment  addressed  to  the  septic  cause. 

PARAPHIMOSIS. 

Paraphimosis  has  its  origin  in  certain  malformations,  traumatism, 
or  inflammations,  and  appears  in  many  degrees  of  severity.  In  some 
cases  it  is  easily  reduced;  in  others,  irreducible  without  an  operation. 
There  is  always  the  danger,  in  severe  and  neglected  cases,  of  ulceration, 

710 


PARAPHIMOSIS.  7'  ' 

sloughing,  or  gangrene.  The  appearances  are  more  or  less  constant: 
the  exposed  glans  is  swollen  and  reddened ;  behind  it  is  a  i  ollar  of «  on- 
Bested  mucous  membrane;  behind  iliis  a  deep  furrow  in  which  lies 
the  constricting  band;  and  behind  this,  another  band  of  swollen 
integument. 

An  effort  must  be  made  al  once  to  reduce  the  foreskin.  The  redui  tion 
is  always  painful.  Begin  by  thoroughly  cleansing  and  cocainizing  the 
parts.  Apply  a  compress  saturated  with  a  twenty  per  cent,  solution 
of  i  o.  aine  and  then  wait  ten  minutes. 

Smear  a  little  vaseline  on  the  balano  preputial  furrow,  but  not  over 
the  glans  generally,  else  the  manipulating  angers  will  slip. 


Fig.  573. — Reducing  a  paraphimosis.     (Stewart.) 


The  purpose  is  to  apply  a  slow,  firm,  and  progressive  pressure  to  the 
engorged  tissues,  at  the  same  time  making  traction  forward  on  the  fore- 
skin and  pressure  backward  on  the  glans. 

There  are  several  ways  of  doing  this,  of  which  the  following  is  an 
excellent  method:  grasp  the  penis  behind  the  glans,  between  the  first 
and  second  fingers  of  each  hand,  and  while  these  make  compression 
and  traction,  the  two  thumbs  are  braced  against  the  apex  of  the  glans 

(Fig-  573)- 

After  reduction  is  accomplished,  measures  must  be  employed  to  sub- 
due the  inflammation  and  the  patient  advised  of  the  necessity  for  a 
( in  umi  ision  later  to  insure  against  a  recurrence. 


712 


PARAPHIMOSIS. 


If  reduction  cannot  be  accomplished  by  these  measures,  an  operation 
must  be  done  without  delay.  The  purpose  is  to  divide  the  restricting 
band,  which  lies  in  the  groove  between  the  two  ridges. 

Inject  a  little  cocaine  along  the  line  of  incision  which  is  usually  in 
the  middle  line  of  the  dorsum  and  just  behind  the  corona  (Fig.  574). 

Use  the  point  of  the  knife,  making  short,  firm,  shallow  cuts,  until  the 
constricting  band  is  felt  to  yield.  A  too  bold  incision  may  result  in 
seriously  wounding  the  corpora  cavernosa. 


Fig.  574. — Dividing  the  constricting  band  in  paraphimosis.      (Veau.) 


The  bleeding  in  any  event  will  usually  be  free  but  ceases  spontane- 
ously. The  wound  which  at  first  was  vertical,  becomes  transverse 
when  reduction  is  completed,  and  is  sutured  in  that  direction. 

Apply  a  moist  dressing  and  if  there  is  no  ulceration  or  gangrene,  the 
swelling  will  soon  subside.  But  in  this  case  also  the  patient  must  be 
advised  of  the  danger  of  recurrence  unless  a  circumcision  is  done  for 
the  relief  of  the  narrowed  prepuce  or  the  short  frenum  after  the  in- 
flammation has  subsided. 


OP]  R  \  ii"--    FOB    I  II-1  i  m<  [SION. 


713 


CIRCUMCISH  »\ 

This  is  an  excellent  operation  probably  nol  often  enough  done  in 
infamy,  when  it  is  simple  and  without  danger,  and  may  prevent  the 
nsturbances  of  adolescence,  consequent  upon  phimosis. 

In  adult  life  it  is  often  the  primary  step  toward  the  relief  of  acute 

disorders  and  sexual  irregularities. 

The  Operation.  General  anesthesia  is  nearly  always  indicated  in 
children;  local,  in  adults.  To  secure  local  anesthesia,  begin  by  Lightly 
fcmponing  the  preputial  orifice  with  a  pledget  of  cotton  saturated  with 


Fig.  575. — Resection  of  the  prepuce.     (Veau.) 


ten  per  cent,  solution  of  cocaine,  and  left  in  position  for  at  least  five 
ninutes.  Next  inject  the  foreskin  in  the  line  of  the  proposed  incision, 
sing  a  four  per  cent,  solution  of  cocaine  or  Schleich's  solution.  The 
do  rapid  absorption  of  cocaine  may  be  prevented  by  constriction  of 
ne  base  of  the  penis. 

When  the  anesthesia  is  established,  break  up  the  preputial  ad- 
esions  with  a  grooved  director  or  probe,  usually  not  difficult  in  an 
lfant  but  sometimes  difficult  in  the  adult,  following  balanitis. 

There  are  various  methods  of  making  the  incision,  any  of  which, 
roperly  employed,  will  give  good  results.  Suppose  the  prepuce  is 
>ng  and  slender:  begin  by  holding  the  penis  vertically  and  without 


714 


CIRCUMCISION. 


making  traction  on  the  foreskin,  apply  a  forceps  so  that  its  blades  lie 
parallel  with  the  oblique  line  of  the  corona  (Fig.  575).  Use  care,  of| 
course,  not  to  pinch  the  glans.  Divide  the  foreskin  with  the  bistoury, 
allowing  the  blade  to  hug  the  upper  side  of  the  forceps,  that  no  bruised 
tissues  may  be  left  behind.  The  skin  retracts,  leaving  the  mucosa 
covering  the  glans.  Divide  this  mucous  covering  along  the  middle  line 
to  within  one-fifth  inch  of  the  coronal  border  (Fig.  576).  The  glans 
will  now  be  completely  exposed. 

Trim  off  the  two  mucous  flaps  so  that  a  narrow  cuff  is  left.     It  is 
better  to  begin  near  the  frenum  and  trim  toward  the  terminal  point  of 


Fig.  576. — Splitting  the  mucous  membrane.      (Veau.) 


the  dorsal  incision  (Fig.  577).  If  the  frenum  is  too  short,  divide  it 
transversely  with  the  scissors  (Fig.  578),  catching  up  the  little  artery 
which  will  be  divided.     This  completes  the  necessary  incisions. 

Hemostasis  must  be  assured.  It  may  be  necessary  to  tie  two  or 
three  small -vessels  and  nearly  always  the  artery  of  the  frenum  re- 
quires ligation,  using  catgut  No.  1. 

A  brief  application  of  adrenalin  solution  on  a  compress  will  check 
the  oozing  if  it  should  persist. 

Suture.  The  mucous  and  cutaneous  borders  are  brought  into  exact 
contact  and  united  by  several  small,  interrupted  sutures  of  catgut  (Fig. 


I  J 1  - «  i   \i<  [SION. 


/'5 


Bo.  577. — Resection  of  the  mucous  membrane.     FiG.578. — Section  of  the  frenum.   (.Veau.) 


,.   -Maintaining  coaptation  by  means      Pig.  580. — Aftersection  of  the  frenura  the 
of  a  small  clip.     (Veau.)  raw  edges  are  coapted.      (\ 


716  CIRCUMCISION. 

579).  The  transverse  incision  of  the  frenum  is  made  a  vertical  one 
by  extending  the  glans,  and  is  sutured  in  that  direction  (Fig.  580). 

In  the  case  of  children,  it  may  be  sufficient,  instead  of  suturing,  to 
use  small  clips,  by  which  means,  it  is  claimed,  swelling  is  avoided. 

Dressing. — Wrap  the  penis  in  a  sterile  compress,  leaving  the  glans 
exposed.  Enclose  the  whole  in  a  second  compress  perforated  over  the 
meatus,  and  secure  with  adhesive  strips. 

Adults  require  bromides  to  prevent  painful  erections.  The  dress- 
ings are  not  to  be  changed  unless  soiled.  Remove  the  sutures  and 
re-dress  the  fifth  day.  It  will  probably  require  ten  to  twelve  days  for 
repair  to  be  complete. 

Children  usually  need  a  daily  change  of  dressing.  If  clips  are  used 
instead  of  sutures,  they  are  to  be  removed  at  the  end  of  twenty-four 
hours,  and  if  the  adjustment  was  perfect,  the  reunion  by  that  time 
will  often  be  practically  complete. 

HYDROCELE. 

The  chief  test  of  a  hydrocele  is  its  "translucency."  The  first  treat- 
ment usually  tried  is  tapping  and  the  injection  of  an  alterative.  If 
the  hydrocele  recurs,  then  a  radical  operation  should  be  done.  Often 
this  should  be  resorted  to  from  the  first  without  preliminary  tapping, 
especially  in  the  long-standing  cases,  where  the  tunica  vaginalis  is 
thickened  and  it  is  almost  obvious  that  the  trouble  will  recur. 

Occasionally  the  patient  will  prefer  repeated  simple  puncture  and 
evacuation  without  subsequent  injection,  rather  than  the  more  radical 
procedures  which  will  lay  him  up  for  some  days. 

Tapping. — Anesthesia  is  not  necessary.  Prepare  the  field  as  for  a 
surgical  operation.  Seize  the  tumor  behind  with  the  left  hand  so  as 
to  make  it  tense  in  front.  The  trocar,  held  in  the  right  hand  with 
index  finger  an  inch  from  the  point  to  limit  its  penetration,  is  entered 
with  a  sharp  thrust  into  the  middle  and  lower  part  of  the  anterior  sur- 
face of  the  tumor  (previously  assure  yourself  that  the  testicle  is  notf 
inverted).  Withdraw  the  plunger,  being  careful  that  the  tube  is  notj 
displaced.  When  the  fluid  is  evacuated,  attach  a  syringe  to  the  trocar 
and  inject  a  drachm  of  a  one-half  per  cent,  solution  of  cocaine;  gently 


I IP1  R  \  I  [ON    FOR    IIVl'K'uii  i.i 


717 


piassage  the  scrotum  so  as  i<i  bring  the  solution  in  contaci  with  the 
whole  testicle,  wail  ten  minutes  and  then  Ie1  the  solution  il<  »w  out. 

In  the  meantime  charge  the  syringe  with  a  drai  hm  of  pure  tincture 
■  iodine  and  inject.  Hold  it  for  five  minutes  and  thru  Lei  it  escape. 
Withdraw  the  trocar  and  seal  the  puncture  with  collodion. 

The  next  day  the  scrotal  wall  is  painful,  reddened  and  swollen. 
The  scrotum  must  be  well  supported,  and  moist  compresses  may  give 
some  relief.  The  patient  should  be  kept  in  bed  for  ten  days  and 
warned  that  several  weeks  may  be  required  for  absorption  of  the 
exudates. 


PlG.  581.  —  Incision  for  hydrocele.      (Vcau.) 
RADICAL    OPERATION. 

Sterilize  the  penis,  scrotum,  and  perineum.  Wrap  the  penis  in  a 
terile  compress  and  have  it  held  out  of  the  way. 

Local  anesthesia  may  be  employed,  but  a  general  anesthesia  is  better. 

Make  an  incision  two  inches  long  over  the  middle  of  the  tumor, 
ividing  first  the  several  layers  over  the  tunica  (Fig.  581).  Then  open 
le  tunica  the  whole  length  of  the  wound  and  evert  the  testicle.  The 
mica  is  stitched  to  the  cord  above  and  its  free  borders,  brought  to- 


«j&  CASTRATION. 

gether  behind  the  epididymis,  are  to  be  sutured  to  each  other  (Fig.  582); 
Or,  the  membrane  may  be  resected  completely,  following  close  to  the 
epididymis,  and  if  the  cut  edges  bleed,  they  are  to  be  sewed  with  a  con- 
tinuous suture  (Fig.  583). 


Fig.  582. — Everting  the  tunica  vaginalis.      (Veau.) 

Restore  the  testicle,  insert  a  small  drain,  and  suture  the  scrotum. 
The  drain  should  be  removed  on  the  second  day  and  the  sutures  on  the 
sixth,  and  in  a  day  or  two  longer,  the  patient  may  get  up. 


CASTRATION. 

The  removal  of  the  testicle  is  more  frequently  indicated  as  the  result 
of  cancer  or  tuberculosis,  and  may  be  done  under  either  local  or  general  j 
anesthesia. 

The  incision  begins  just  below  the  external  ring  (on  the  right)  and 
follows  the  direction  of  the  cord  for  from  one  and  one-half  to  two  j 
inches  (Fig.  584). 

Expose  and  isolate  the  cord  up  to  the  inguinal  canal  which,  if  in- 
volved, should  be  opened,  as  in  the  operation  for  hernia.  Separate 
the  different  elements  of  the  cord,  so  as  to  require  two  or  three  separate 


CASTH  \  I  [ON. 


7"' 


po.  583. — Hydrocele:     Resection  of  the  tunica  Fig.  584. — Incision  for  castration, 

vaginalis.     (Vcau.)  (Veau.) 


Fin.  585.— Ligation  of  the  spermatic  cord.     {Veau.) 


720 


CASTRATION. 


ligatures.     Do  not  include  the  cremaster  in  the  ligatures  (Fig.  585). 
Just  below  the  catgut  ligatures,  resect  the  cord  and  enucleate  the  tes-] 
tide  from  above  downward  (Fig.  586). 

This  step  is  usually  tedious  in  the  tubercular  cases  on  account  of! 
the  adhesions  which  may  have  to  be  divided  with  the  bistoury,  and 
the  bleeding  points  tied. 


Fig.  586. — Separating  the  testicle  from  the  scrotal  tissues.     (Veau.) 


Again  inspect  the  cord  (you  have  left  the  ligatures  long  till  now) 
to  be  sure  there  is  no  bleeding;  and  it  is  recommended  to  cauterize  the 
end  of  the  vas  in  tuberculosis. 

Repair  first  the  inguinal  canal,  if  it  was  opened.  Insert  a  drainage- 
tube  reaching  to  the  bottom  of  the  scrotum  and  projecting  from  the: 
upper  angle  of  the  wound  which  is  the  point  least  likely  to  get  infected 
after  the  dressings  are  applied.  The  tubercular  cases  especially 
require  drainage.  Suture  and  apply  a  dry  dressing.  Remove  tha 
tube  on  the  third  and  the  sutures  on  the  sixth  or  seventh. 


(   IIAI'IIR   XXV. 
INGROWING   TOE-NAIL. 

The  particular  point  in  tin's  operation  is  to  obliterate  the  matrix  cor- 
fesponding  to  the  pari  of  the  nail  removed.  It  is  insufficient  to  re- 
move only  that  part  of  the  nail  gouging  the  flesh.  Usually  one  side 
only  is  involved,  the  outer  side,  and  the  removal  of  half  the  nail  will 
effect  a  cure. 


Fig.  587. — Local  anesthesia.     (Veau.) 


Employ  local  anesthesia.  Constrict  the  base  and  make  a  circular 
njei  lion  of  cocaine  or  stovaine  (Fig.  587). 

Remove  the  Nail.  Introduce  the  sharp  point  of  the  scissors  under 
be  nail  and  divide  its  entire  length  (Fig.  588).  Next  seize  the  diseased 
prtion  with  a  forceps  and  tear  it  out  (Fig.  589). 

Extirpate  the  Matrix.  Incise  the  integument  of  the  matrix  to  be 
46  7  j  1 


722 


INGROWING   TOE-NAIL 


Fig.  s 88. — Splitting  the  nail.     (Veau.)  Fig.  589. — Wrenching  the  nail  out.     (Veau.) 


Fig.  590. — Incision  over  the  matrix.      (Veau.)      Fig.  591. — Extirpation  of  matrix.      (Veau.) 


INGROWING     I  "I     NAIL. 


eliminated,  with  a  sharp  pointed   bistoury,  holding  the  cutting  poinl 
obliquely,  so  thai  it  gets  a  larger  bite  deeply  than  superficially  (1 
590).    The  soft  parts  are  thus  removed  down  f"  th<-  bone  (Fig.  591). 
A  deep  cavity  is  Left  in  the  bottom,  <>f  which  the  bone  may  be 


Fig.  592. — The  matrix  removed.     (Veau.) 


A.M 

Fig.  593. — Wound  sutured.     (Vcau.) 


(Fig.  592).  This  cavity  should  be  packed  with  sterile  gauze  and 
allowed  to  heal  by  granulation,  which  will  require  two  or  three  wicks. 
It  is  advisable  to  diminish  the  size  of  the  cavity  by  a  suture,  including 
on  one  side  the  skin,  and  on  the  other,  the  subungual  tissues  (Fig.  593). 
It  will  probably  give  way  finally,  yet  it  facilitates  repair. 


CHAPTER  XXVI. 


REMOVAL  OF  SMALL  TUMORS. 

The  technic  for  the  removal  of  small  tumors  on  or  under  the  skin 
should  be  kept  in  mind.  As  in  more  difficult  operations,  a  definite 
procedure  should  be  followed.  A  lack  of  system  may  make  a  minor 
matter  one  of  difficulty. 

Local  anesthesia  will  usually  suffice.  It  should  be  complete.  To 
secure  a  complete  local  anesthesia,  begin  by  determining  the  lines  of 
incision,  and  along  these  lines  inject  a  two  per  cent,  solution  of  cocaine; 


Fig.  594- — Anesthesia  of  the  skin. 
(Veau.) 


Fig.  595. — Anesthesia   of  the   deeper  layers. 
(Veau.) 


intradermic,  not  subcutaneous.  If  the  tumor  is  large  or  if  the  skin  is 
loose,  redundancy  may  be  avoided  by  making  two  semicircular  in- 
cisions, thus  removing  an  ellipse  of  the  skin  (Fig.  594). 

Next  loosen  the  edges  of  the  skin  and  partially  expose  the  tumor 
and  make  a  new  injection  along  its  sides.  Later  inject  the  base  of  the 
tumor  as  the  dissection  proceeds  (Fig.  595). 

In  the  case  of  sebaceous  cysts,  the  main  point  is  to  remove  the  sac  in 
its  entirety;  anything  else  insures  a  return  of  the  trouble.     If  possible, 

724 


Rl  \iu\  \|     01    ->i  BAI  i  "i  g    CYSTS. 


725 


Kissed  the  sac  out  without  emptying  its  contents.  The  dissection  will 
he  done  with  rase  only  in  1  ase  all  the  layers  arc  Ln<  ised  down  to  the  true 
capsule.  If  the  cyst  walls  an-  particularly  thick,  the  contents  may  he 
emptied  out  from  the  first. 

(  >m  c  the  1  J  Si  is  exposed  retract  <nie  lip  of  the  skin  wound  and  loosen 


Fig.  596. — Detaching  the  capsule.     (Vcau.) 


Fig.  597. — Dissecting  a  loose  capsule  with  the  bistoury.     (Veau.) 

the  attachments  by  blunt  dissection   (Fig.   596).     Or  if  the   fibrous 
attachments  are  loose  and  tough,  divide  them  with  scissors  or  scalpel 

(Fig-  597)- 

There  will  be  some  slight  hemorrhage  from  the  cavity   following 
the  removal  of  the  cyst,  but  it  will  be  easily  controlled  by  pressure  or 


726  REMOVAL   OF   SMALL   TUMORS. 

by  a  hot  compress.  In  case  the  cyst  was  emptied  in  the  course  of  the 
operation,  be  assured  that  all  the  cyst  wall  is  removed,  or  the  growth 
will  recur. 

The  procedure  is  the  same  in  the  case  of  a,  fatty  tumor  unless  it  is 
pedunculated;  if  so,  make  a  curved  incision  on  each  side  of  its  base. 
Usually  a  small  blood  vessel  at  the  base  of  the  tumor  will  require 
ligation. 

Synovial  cysts  require  special  attention  to  asepsis  or  the  cavity  with 
which  they  are  connected,  and  from  which  they  originate,  may  become 
infected;  thus  an  arthritis  or  teno-synovitis  might  develop.  The 
pedicle  requires  careful  ligation. 

Branchial  cysts  are  often  intimately  connected  with  the  vessels  in  the 
neck  and  their  dissection  may  be  extremely  difficult.  The  pedicle  of 
such  cysts  usually  terminates  in  the  thyro-glossal  duct. 

Angiomas  are  likely  to  give  rise  to  dangerous  hemorrhage.  Only 
such  as  are  small  and  well  defined  should  be  undertaken  by  the  prac- 
titioner. No  effect  should  be  made  to  enucleate;  instead  elliptical 
incisions  should  be  made  quite  beyond  the  borders  of  the  tumor  and 
the  whole  removed  "en  masse."  Usually  a  well-defined  vascular 
pedicle  will  require  careful  ligation. 


CHAPTER  XXVI I. 
SKIN  GRAFTING. 

Skin  grafting  is  a  measure  deserving  to  be  more  generally  employed 

l>y  the  practitioner.  Very  often  it  would  save  time  and  trouble  in  the 
treatment  of  those  conditions  in  which  epidermitization  is  long  de- 
layed, for  this  it  hastens  and  also  it  tends  to  prevent  the  formation  of 
scar  tissue.  Thus  chronic  ulcers,  burns,  and  lacerated  wounds  fol- 
lowed by  extensive  sloughs  may  require  grafting. 

The  operation  is  simple  in  theory  yet  attended  by  many  failures 
through  lack  of  attention  to  detail. 

Three  factors  require  the  minutest  supervision:  (i)  the  field  must 
be  properly  prepared;  (2)  the  grafts  must  be  cut  correctly;  (3)  the 
after-treatment  must  be  appropriate. 

(1)  The  area  to  be  grafted  must  be  sterile  and  must  be  free  of  any 
oozing.  If  an  ulcer  is  to  be  treated,  the  granulations  must  previously 
be  made  as  healthy  as  possible:  if  sluggish,  by  currettement;  if  exuber- 
ant, by  touching  up  with  nitrate  of  silver.  A  few  days  afterward  it  will 
be  ready  to  receive  the  graft.  A  dry  sterile  dressing  should  be  applied 
a  day  previous  to  the  operation;  before  the  graft  is  applied,  the  surface 
should  be  thoroughly  douched  with  normal  salt  solution. 

(2)  The  skin  which  is  to  furnish  the  graft  should  be  shaved  and 
thoroughly  scrubbed  with  soap  and  water.  Antiseptics  had  better 
be  avoided  for  they  may  compromise  the  vitality  of  the  cellular  ele- 
ments. A  sufficient  anesthesia  may  be  obtained  by  injection  of 
Si  hleich's  solution  No.  3. 

Two  methods  of  cutting  the  grafts  are  currently  employed,  Rever- 
din's  and  Thiersch's. 

(I)  Reverdin's  Method. — A  small  fold  of  the  skin  is  picked  up  with 
tine  tissue  or  mouse-toothed  forceps  and  cut  off  at  its  base  with  small 
pointed  scissors  (Fig.  598).  This  section  includes  practically  all  the 
layers  of  the  skin  (Fig.  599).     The  graft  is  appb'ed  and  gently  pressed 

727 


728 


SKIN   GRAFTING. 


out.  Fifteen  or  twenty  points  are  thus  placed  about  15  mm.  or 
say  1/2  inch  apart.  If  the  surface  is  large  enough  to  require  more,  the 
center  should  be  left  bare  and  treated  by  a  second  operation  (Fig.  600). 


A 


Fig.  598. — Manner  of  cutting  the 
Reverdin  graft.     (Veau.) 


Fig.  599. — The  graft 
removed.     {Veau.) 


(II)  Thiersch'' s  Method. — This  method  is  the  better  when  it  succeeds, 
but  the  conditions  of  success  are  more  exacting.  Granulation  tissue 
usually  needs  to  be  removed  by  curettement,  exposing  the  fibrous  layer. 


Fig.  600. — Placing  Reverdin  grafts.     Ulcer  of  leg.     (Veau.) 

The  edges  of  the  ulcer  must  be  scraped  (Fig.  601).  The  oozing  which 
follows  must  be  completely  checked.  A  firm  compress  applied  for  ten 
or  fifteen  minutes  will  usually  suffice.  If  oozing  persists,  the  operation 
will  fail. 


I  llll    RS<   II   S     Ml    I  I  lop. 


729 


The  grafts  in  this  1  ase  1  onsisl  of  thin  sli<  es  of  the  epidermis,  as  long 

as  necessary  ami  a-  wide  as  .  <ni\ rnicnt.      They  arc  usually  taken  from 


Fig.  601. — Thiersch's  method:     Preparing  the  wound  for  the  graft.     (Veau.) 

the  anterior  surface  of  the  thigh.     A  sharp,  thin-bladed  razor  is  used  in 
cutting  the  slice  (Fig.  602). 


Fig.  602. — Cutting  the  Thiersch  graft.     (Vcau.) 

The  skin  must  he  put  on  the  stretch.      Special  retractors  are  occa- 
sionally employed.     The  two  hands  of  the  assistant  and  the  left  hand 


73° 


SKIN    GRAFTING. 


of  the  operator  can  make  it  sufficiently  tense  (Fig.  603).  The  razor 
is  held  nearly  horizontally  and  cuts  by  a  rapid,  short,  sawing  motion. 
As  the  razor  progresses,  the  thin  and  pliable  tissue  piles  up  on  the 
blade. 

The  graft  is  now  applied  to  the  raw  surface  and  the  free  end  fixed  by 
a  pointed  instrument  and  slowly  worked  off  the  blade,  and  then 
teased  out  flat  (Fig.  604). 


Fig.  603. — Cutting  the  Thiersch  graft.     (Veau.) 


So  proceed  until  the  whole  surface  is  covered.  Small  angles  may 
be  filled  in  with  Reverdin  grafts  (Fig.  605).  The  area  denuded  need 
only  to  be  covered  with  a  sterile  dressing  and  repair  will  soon  be 
complete. 

(3)  The  grafted  area  must  be  carefully  covered  with  strips  of  rubber 
tissue  or  gutta-percha,  placed  in  various  directions  so  as  to  hold  the 
grafts  in  place  and  at  the  same  time  give  exit  to  any  exudates.     A 


Mill   RS<   II   S  "Ml    I  HOD. 


731 


layer  of  gauze  saturated  with  salt  solution  is  next  applied,  which  in 
turn  is  covered  by  absorbent  cotton,  and  the  whole  held  in  place  by  a 
moderately  firm  bandage. 


/"\ 


Fig.  604. — Method  of  applying  the 
graft.     (Veau.) 


Fig.  605. — Wound  covered  by 
grafts.     {Veau.) 


The  part  should  be  immobilized,  employing  plaster  splints  if  neces- 
sary. Change  all  the  dressings  except  the  rubber  tissue  every  day  or 
two  and  douche  gently  with  normal  salt  solution.  At  the  end  of  a 
week  or  ten  days,  change  the  tissue. 


INI)  E  X . 


Abdomen,  a  mtusii  >ns,  i  1 2 

gunsh< 't  wounds,  [34,  [45, 

incised  wounds,   1  1  (1 

injuries,  1  1  a 
laparoti >my,  i  1  3 
non-penetrating  wounds,  1 

penetrating  wounds,  1  1  5 
punctured  wounds,  1  1  5 
Stab  wounds,  i  1  5 
AImI, iminal  drainage,  1  1  7 
hemorrhage,  465 

section,  463 
Abducens  nerve,  297 
Abscess,  acute,  312 

alveolar,  321 

antrum,  mastoid,  455 

appendiceal,  503 

axillary,  332 

Bartholin's  gland,  346 

breast,  330 

cervical  glands,  329 

chronic,  31  5 

definitions,  312 

dental,  321 

drainage,  314 

eyelids,  318 

external  auditory  meatus, 

lace,  317 

floor  1  >t  tlie  mouth,  323 

iliac,  355 

ischio-rectal,  337 

kidney,  484 
labium,  346 
lachryn  al,  319 

liver,  351 
lung,  436 

mammary,  330 
mastoid,  455 
nasal  septum,  318 

palmar,  335 

parotid,  320 

pelvic,  348 

peri-anal,  340 


AbsceSS,  perineal,  34  1 
1  5.)  plantar,  337 

popliteal,  335 
pr<  'Static,  34  1 
psoas,  3  55 
14  rectal,  340 

retropharyngeal,  326 
scalp  subaponeurotic,  316 

subperiosteal,  317 
superficial,  3  1  6 

seminal  ducts,  345 

submaxillary,  322 

submammary,  332 

subphrenic,  3  51 

symptoms  of,  312 

tongue,  325 

tonsillar,  325 

treatment,  acute,  313 
chronic,  315 

urinary,  633 

vulvar,  346 

vulvo-vaginal,  346 
Accidents,  anesthesia,  14 
Acupressure,  58 
Acute  intestinal  obstruction,  508 

retention  of  urine,  619 
319        Actual  cautery,  phlegmon,  368 

Adrenalin  chloride  anesthesia,  14 

epistaxis,  65 

gauze  tape,  61 

shock,  52 
Air  passages,  foreign  bodies,  396 

burns,  409 
Alcohol,  antisepsis,  3 
Allison,  strangulated  hernia,  539 
Alveolar  abscess,  321 
Ammonia  after  anesthesia,  16 
Amputations,  arm,  670 

atypical,  650 

Chopart,  685 
elb< iw,  <>7o 
finger,  057 
foot,  684 

733 


734 


INDEX. 


Amputations,  forearm,  666 

great  toe,  68 1 

hand, 664 

hip-joint,  698 

index  finger,  659 

knee-joint,  695 

leg,  693 

little  finger,  657 
toe,  682 

metacarpal,  662 

metatarsal,  683 

middle  finger,  654 
toes,  682 

Pirogoff's,  689 

principles,  649 

Syme's,  687 

thumb,  atypical,  664 
typical,  661 

thigh,  697 

toes,  680 

scapulo-humeral,  679 

shoulder,  674 
Anal  abscess,  340 

dilatation,  703 

fistula,  709 
Anastomosis,  intestinal,  573 
Anderson,  Cesarean  section,  607 
Andrews,  Colles'  fracture,  215 
Anesthesia,  1 1 

accidents,  14 

ammonia,  16 

chloroform,  1 1 

cocaine,  17 

ether,  13 

ethyl  chloride,  17 

local,  17 

spinal,  20 

stovaine,  20 

vomiting,  16 
Aneurism,  gunshot,  123 
Aneurismal  varix,  125 
Angina,  Ludwig's,  323 
Angiomas,  726 
Angus,  torsion,  593 
Ankle  amputation,  687 

arthrotomy,  383 

dislocation,  277 

fracture,  242 

sprain,  282 
Anterior  crural  nerve,  exposure,  304 

injury,  303 
Anterior  tibial  artery,  ligation,  646 

nerve,  injury,  309 
Antipyrine,  epistaxis,  65 


Antisepsis,  emergency,  6 
Antiseptics,  3 
Antitetanic  serum,  167 
Antistreptococcic  serum, phlegmon 

324 
Antrum,  mastoid,  455 
Anus,  abscess,  340 

artificial,  permanent,  523 

temporary,  519 
dilatation,  703 
fistula,  709 
imperforate,  584 
piles,  704 
Appendectomy,  498 
Appendicial  abscess,  503 
Appendicitis,  488 

after  treatment,  50  5 
catarrhal,  491 
diagnosis,  488 
gangrenous,  491 
operation,  498 
perforating,  491 
treatment,  498 
ulceration,  491 
varieties,  491 
Appendix  in  hernia,  544 
Arm,  amputation,  670 
bandages,  42 
fractures,  195 
phlegmons,  366 
Aristol  in  burns,  408 
Arrest  of  hemorrhage,  57 
Arteries,  ligations,  rules,  638 
suture,  638 
torsion,  59 

wounds,  gunshot,  122 
Arterial  hemorrhage,  54 
Artery  forceps,  4 

ligation,  anterior  tibial,  646 
axillary,  643 
brachial,  643 
common  carotid,  640 
compression,  63 
dorsalis  pedis,  647 
external  carotid,  641 
femoral,  646 
lingual,  641 
obturator,  306 
posterior  tibial,  647 
radial,  644 
subclavian,  641 
ulnar,  645 
Artificial  anus,  permanent,  523 
temporary,  519 


I\l'l  \. 


735 


An ificial  limbs,  693 

respiral  i(  »n,  1  5 
Art luit is,  septic,  376 
An  hrotomy,  377 

ankle,  383 

elbi  >w,  $8  i 

hip,  385 

knee,  37  7 

shoulder,  385 

wrist ,  384 
Asphyxia,  anesthesia,  1  5 

foreign  1"  idies,  393 

retropharyngeal  abscess,  327 
Aspirat  i<  in,  bladder,  6  1  6 

pericardium,  433 

pleura,  438 
\      agalus,  disli ication,  277 
Auditory  nerve,  injuries,  297 
Automatic  centers,  paralysis,  12 
Axillary  artery,  ligation,  643 

abscess,  acute,  334 
chr<  »nic,  334 
Axtell,  wound  of  chest,  107 

trephining,  453 

Bandage,  Barb  m's,  44 
arm,  4  2 
breast,  4  1 
eye,  44 
anger,  41 
foot,  35 
groin,  38 
hand,  42 

head,  44 
knee,  37 
leg,  36 
neck,  42 
sin lulder,  42 
St.  Andrew's  cross,  40 
stump,  45 
thumli,  41 
Bandages,  34 

method  of  applying,  3  5 

plaster,  46 
Bartholin's  gland,  abscess,  346 
Hart. in's  bandage,  44 
Base  of  thorax,  wounds,  108 
Bassini,      operation      for      hernia, 

5  58 
Bavarian  splints,  48 
Bi -lt'u  Id,  drainage  of  seminal  dints, 

345 
Bellocq's  cannula,  66 

Bennett,  Sir  \\\,  torsions,   592 


Bennett'    fracture,  123 
Biceps  tindoii  disl< >ca1  i< >n,  38  1 

ude,  1  at  heter,  iuo 
Bier  t  reatmenl ,  36] 
"  Black  eye,"  69 
Bladder,   aspiration    in   retention, 

628 

Bladder,  i  v   1 .  .I.  .1 1 1  \  .  639 

ii  ireign  1"  idies,  403 
hernia  operatii in,  5  1  j 

gunshol   wounds,   135 

puncture,  628 
rupture,  485 

suture,  48(1 
wounds,  485 

Blank  cartridges,  1  66 
Bleeding  (see  Hemorrhage) 
Bloodgood,  intestinal   obstruction, 
508 
fractures,  191 

Blood  vessels,  injuries,  88-90 
Boldt,  scopolamine  narcosis,  14 
Bolo  wounds,  146 
Bone  wiring,  216 
Bonney,  emergency  operations,  6 
Bowel,  acute  obstruction,  508 
Bowls,  sterilization,  10 
Brachial  artery,  compression,  63 

ligation,  643 
Brain,  abscess,  144 

compression,  176 

concussion,  1  74 

contusii  >n,  1  76 

gunshot  wounds,  129,  143 

hemorrhage,  444 

injuries,  169 

topography,  445 
Branchial  cysts,  726 
Breast  abscesses,  330 

bandage,  41 
Brickner,  tubal  pregnancy,  598 
Bronchi,  foreign  bodies,  396 
Bronchoscopy,  Killian,  398 
Brown,  Cesarean  section,  606 
Bruises  (see  Contused  wounds) 
Brushes,  hand,  2 
Bryant,  esophagotomv,  422 
Bullet  wounds,  civil,  1  55 

military,  122 
Bullets,  types,  1  23 
Burns  and  scalds,  405 
Burns,  air  passages,  401) 
Burns,  electrical,  4  1  o 
Burns,  mouth,  400 


736 


INDEX. 


Cahill,  torsions,  592 

Calmette's      antitetanic      powder, 

167 
Cannaday,      subcuticular      suture, 

28 
Capitellum,  43 
Carbuncle,  318 
Carpus,  dislocation,  280 

fracture,  219 
Carotid  artery  compression,  63 

ligation,  640 
Carron  oil,  409 
Carstens,  empyema,  438 
Castration,  718 

emergency,  120 
Catheterization  equipn  ent,  620 

retrograde,  617 
Catgut,  24 

chromicized,  24 
Catheters,  box  for,  4 

sterilization,  620 

acute  retention,  620 
Cecum  in  hernia,  542 
Cerebro-spinal     fluid,     characters, 

170 
Cervical  glands,  suppuration,  329 
Cesarean  section,  604 
Championniere,  fractures,  192 
Chest  contusions,  103 

wounds,  104 
Cheyne,  phlegmon  of  neck,  368 
Chloral,  wounds  of  tongue,  82 
Chloroform  anesthesia,  1 1 
face  in,  12 
pulse  in,  12 
pupil  in,  1 2 

container,  12 
Chipman,    reduction   of    shoulder, 

261 
Chopart's  amputation,  685 
Cigarette  drain,  30 
Circular  enterorrhaphy,  575 
Circumflex  nerve,  exposure,  302 

injury,  302 
Circumcision,  713 
Clark,  appendicitis,  490 

intussusception,  515 
Clavicle,  fracture,  183 
Cocaine  anesthesia,  1 7 
Coley,  femoral   hernia,  569 
Collapse,  50 
Colles'  fracture,  212 
Colon  bacillus,  488 
Colostomy,  523 


Colpotomy,  348 

Combs,    foreign    body   in   rectum, 

401 
Comminuted  fractures,  168 
Compound  dislocations,  278 
elbow,  280 
hip,  280 
knee,  280 
shoulder,  280 
fractures,  246 

ankle  and  foot,  2  50 
Compression  of  arteries,  brachial, 63 
carotids,  63 
coronary,  63 
facial,  63 
occipital,  63 
subclavian,  63 
temporal,  63 
of  brain,  176  - 
Concussion  of  brain,  174 
Condyles  of  humerus,  fracture,  207^ 
Congenital  hernia,  557 
Coin  catchers,  394 
Conjunctiva,  foreign  bodies,  388 

wounds,  85 
Continuous  suture,  24 
Contusions,  69 
abdomen,  112 
brain,  175 
chest  wall,  103 
eye,  85 
eyelid,  82 
knee-joint,  281 
lung,  103 
nerves,  294 
scalp,  78 
urethra,  611 
Cook,  appendicitis,  495 
Corner,  torsions,  596 
Coracoid  process,  examination,  200 
Coronary  artery,  compression,  63 
Cotton,  injuries  to  testicle,  120 
Cranial  nerves,  injuries,  296 
Craniectomy,  emergency,  444 
Crepitus,  189 
Crile,  direct  transfusion,  56 

shock,  51 
Crushing   injuries   to  the  extremi- 
ties, 90 
Cullen,  596 
Cushing,  shock,  53 
Cut  throat,  83 

wrist,  88 
Cystotomy,  operation,  617,  629 


[\l'l  \. 


737 


Deep  epigastric  artery,  <> 5 
Dental  abscess,  3  -•  1 
Depressed  fracture,  skull,  1 7 -• 
Diaphragm,  wounds,  1 10 
I'      Lai  arteries,  compression,  64 
Pilatati<  >n  <  >f  the  amis,  70  $ 
urel  oral  s1  rid  ure,  6a  2 
I     pressure    in     hemorrhage, 

57 
Disli  ical  i<  'us,  j  52 
ankle,  277 
c<  impound,  a  78 
elbow,  -<>(> 
finger,  270 
hip,  270 
jaw,  a66 

knee,  276 

patella,  277 
sh<  iulder,  a  5a 
after-treatment,  365 
subclavicular,  2  56 
subglenoid,  262 
subspinous,  265 
semilunar  cartilages,  2 70 
thumb,  268 
wrist,  j So 
Dixon,  tubal  pregnancy,  598 
Dorsalis      pedis      artery      ligation, 

647 
Dorsum  ilii,  dislocation,  270 
Double  spica,  40 
Downey,  fracture  of  femur,  231 
I  ><  lyen's  trephine,  448 
Drainage,  29 

abdominal,  1 1 7 
abscess,  3  1 4 
accidental  wounds,  31 
amputations,  650 
appendicitis,  503 
arthrotomy,  378 
aseptic  wounds,  29 

cigarette,  30 
Compound  fractures,  31 
empyema,  442 
gauze  wick,  30 
heart  wounds,  430 

operative  w<  lunds,  3 1 

tld>es,  30 

urinary  infiltration,  637 
I  >n  jsings,  32 

tirst  aid,  1  41) 

frequency,  33 
Dupuytren's  splint,  243 
Dura  mater,  wounds,    151 

47 


1  >ui.  h  cane    plinl  .  15,  138 
;  1       nea,  heart  wound  ,  1 1 1 

Ear  drum,  paracentesi  .  156 

forceps,  300 

f.  ireign  1  m 
Bastman,  J.  R.,  hernia,  565 

intestinal  1  »DSl  ruction,  509 

Bastman,  T.  B .,  appendiciti 
1     ■  ipic  gestation,  597 
Edema  01  glottis,  419 
Elbow,  amputation,  ^70 
arthrotomy, 

dish  nation,  266 

fracture,  206 

gunshot  wi  Hinds,   142 

wound,  90 
Electrical  burns,  410 

shock,  410 
Elliott,  wounds  of  kidney,  484 
Emergency  antisepsis,  (1 

operations,  preparation,  6 

surgery,  equipment,  2 
military,  153 
Emphysema,  chest  injuries,  101 
Empyema  of  thorax,  436 

adult,  440 

after-treatment,  443 

child,  43Q 

diagnosis,  436 

puncture  for,  438 
Enemas,  technic,  511 
Enterostomy,  519 
Enterectomy,  573 
Enterorrhaphy,  575 
Epistaxis,  65 

Equipment,  emergencies,  a 
Esmarch  bandage,  62 
Esophagotomy,  420 
Esophagus,  foreign  bodies,  392 

wounds,  85 
Estes,  intussusception,  513 

Ether  anesthesia,   13 

adrenalin  chloride  in,  14 
External  auditory  meatus  abscess, 
319 

carotid  artery  ligation, -04  1 

urethrotomy,  <>i  2 
Extra-capsular  fracture.  224 
Extravasation  of  urine,  633 
Extremities,  fractures,  iss 

wounds,  87 
Eye  bandage,  44 

foreign  bodies,  388 


738 


INDEX. 


Eye  injuries,  85 
Eyelid,  abscess,  318 

contusion,  82 

wounds,  82 

Face,  abscesses,  317 

fractures,  180 

furuncle,  317 

gunshot  wounds,  144 

wounds,  81 
Facial  artery,  compression,  63 
ligation,  641 

nerve  injuries,  296 

mastoid  operation,  461 
Femoral  artery,  compression,  64 
ligation,  646 
stab  wound,  88 

hernia,  anatomy,  546 
radical  cure,  567 
strangulated,  546 
taxis,  533 
Femur,  amputations,  697 

fractures,  224 

osteomyelitis,  374 
Fibula,  fractures,  236 
Field    of    operation,     sterilization, 

10 
Figure-of-eight  bandage,  35 
Fingers,  amputations,  651 

bandages,  41 

dislocations,  270 

fractures,  220 

infections,  359 
First  aid,  dressing,  148 

fractures,  194,  223 

hemorrhage,  62 

splints,  151 
Fiske,  wounds  of  spleen,  483 
Fistula,  anal,  709 

urinary,  633 
Floor  of  mouth,  abscess,  323 
Foot,  amputations,  684 

bandages,  35 

fractures,  250 
Forceps,  artery,  4 

aural,  390 

nasal,  392 

urethral,  402 
Forcipressure,  59 
Ford,  ether  anesthesia,  14 

fracture  of  patella,  232 
skull,  452 
Forearm,  amputation,  666 

phlegmon,  365J 


Foreign  bodies,  air  passages,  396 

bladder,  403 

ear,  389 

esophagus,  392 

eye,  388 

larynx,  396 

nose,  391 

pharynx,  392 

rectum,  399 

trachea,  396 

urethra,  402 
Fountain  syringe,  3 
Fowling  piece,  gunshot  wound,  165 
Foxworthy,  bolo  wounds,  146 
Fractures,  168 

ankle,  250 

arm,  195 

carpus,  219 

Colles',  212 

clavicle,  183 

compound,  246 

condylar,  207 

crepitus,  189 

definitions,  168 

diagnosis,  189 

elbow,  206 

extremities,  188 

face,  180 

gunshot,  144 

femur,  224 
gunshot,  140 

fibula,  236 

fingers,  220 

first  aid,  194 

foot,  250 

forearm,  210 

gunshot,  136 

hand,  219 

head,  169 

humerus,  195 

immobilization,  192 

intercondylar,  209 

jaw,  lower,  181 
upper,  180 

leg,  236 

malar,  180 

maxillae,  180 

metacarpus,  220 

nasal  bone,  179 

olecranon  process,  216 

pain,  190 

patella,  231 

pelvis,  245 

Pott's,  242 


I\l>l  \. 


739 


Prad  urc  ,  radiu  .  -mo 
reduction,  [91 
ribs,  183 
scapula,  1 1 
skull,   [69 

compound,  17; 
supracondylar,  205 
spine,  178 
splints,  193 
tarsus,  250 
thumb,  22\ 
tibia,  236 

toeS,    250 

treatment,  191 

ulna,  210 

vertebra,  17s 

wrist,  219 
Freezing,  1 1  1 
Fr<  »st  bite,  405 
Furuncle  of  face,  3 1 7 
Fysche,  gunshol  wound,  160 

Gage,  rupture  quadriceps  extensor, 

285 
Gangrene,  amputation,  649 
Gastric  lavage,  14,  510 
Gastro-enterostomy,  478 
Gauze,  4 

dressings,  32 

drainage,  30 
General  practitioner  as  emergency 

surgeon,  1 
Genito-crural  nerve  injury,  307 
Gerster,   treatment  of   peritonitis, 

507 
Gibbon,  suture  of  heart,  430 
Gloves,  rubber,  9 
Gluteal  hernia,  556 
Gi ><>ch's  splint,  45 
Granger,  burns,  409 
Great  toe,  681 
( in  .in,  bandage,  38 
Guibal,  subphrenic  abscess,  351 
Gunshot  fractures,  136 

wound    of   abdomen,   134,    145, 

159 
bladder,  135 
bone,  124 
brain,  129,  14,; 
cranium,  127,  143 
face,   in.   157 

band,  164 
head,  155 
heart,  133 


1  Jun  1 1  •  't  \\i >und  of  inte  tine, 

jl  .lilt      ,     I  .'!.,     I    }l.     163 

kidney,  135 

knrr,    1  1  J,    163 

liver,  135 
lungs,  13a 
neck,  144,  157 

nerves,   [33 

pancreas,  135 

rectum,  135 

skull,  130,  143 

spine,  130,  145,   157 

spleen,  135 

stomach,  135 

thorax,  132,  145,  158 

trachea,  144 
wounds,  civil,  155 

effects  on  tissues,  122 

hemorrhage,  122 

military,   122 

prognosis,  135 

shock, 122 

suicidal,  156 

treatment,  135 
Gun-splint,  154 
Guyon,  catheterization,  626 

Hand,  abscess,  335 

amputations,  664 

bandages,  42 

brushes,  2 

fractures,  219 

gunshot  wound,  164 

infections,  361 

injuries,  96 

sterilization,  9 
Harrington's  solution,  10 
Harsha,  torsions,  592 
Hartmann,  splenectomy,  595 
Havard,  gunshot  wounds,  134,  146 
Hayes,  peritonitis,  506 
Haynes,  wounds  of  liver,  47^ 
Head,  wounds,  78 

bandages,  44 
Heart,  gunshot  wounds,  133 

wounds,  no 

massage,  15 

repair,  425 

suture,  430 
Heile,  treatment  of  ileus,  518 
Ihmarthrosis,  142,   [64 
Hematoma,  70 
I  [ematuria,  486 
Hemopericardium,  102 


74Q 


INDEX. 


Hemopneumothorax,  101 
Hemoptysis,  ioo 
Hemorrhage,  54 

acupressure,  58 

adrenalin  chloride,  55 

arrest,  57 

arterial,  54 

capillary,  54 

chemicals  in,  57 

constitutional  effects,  54 

definitions,  54 

diagnosis,  55 

ectopic  gestation,  rupture,  597 

fatal,  55 

first  aid,  62 

forcipressure,  59 

heat,  57 

hypodermoclysis,  56 

infusion,  intravenous,  56 

internal,  54 

intermediary,  54 

kidney,  473 

laparotomy,  465 

liver,  473 

meningeal,  170 

mesentery,  473 

normal  salt  solution,  56 

operative,  50 

parenchymatous,  54 

primary,  54 

secondary,  54 

spleen,  473 

spontaneous  arrest,  57 

symptoms,  54 

torsion,  59 

tourniquets,  58 

treatment,  55 

tubal  pregnancy,  597 

venous,  54 
Hemorrhoids,  operations,  704 
Hemostasis,  57 
Hemothorax,  100,  133 
Hennequin's  dressing,  197 
Hernia,  appendix,  544 

bladder,  543 

cecum,  542 

encysted,  542 

femoral,  567 

gangrenous,  539 

gluteal,  556 

inguinal,  533 

interstitial,  543 

lumbar,  556 

lung,  102 


Hernia,  obturator,  554 

ovaries,  556 

perineal,  556 

preperitoneal,  543 

sciatic,  556 

stomach,  545 

septic  absorption,  528 

sigmoid,  542 

strangulated,  528 

umbilical,  533 

radical  cure,  femoral,  567 
inguinal,  557 
umbilical,  550 
vaginal,  556 
Hernial  sac,  anomalies,  542 
Hernio-laparotomy,  542 
Hertzfeld,  epistaxis,  66 
Hilton,  abscess,  335 
Hip-joint,  arthrotomy,  385 

amputations,  698 

dislocations,  270 

gun-shot  wounds,  142 
Hodgen's  splint,  141 
Holliday,  splenectomy,  482 
Humerus,  fractures,  195 

gunshot,  139 

lower  end,  202 

shaft,  195 

surgical  neck,  200 

upper  end,  198 

osteomyelitis,  374 
Hunt,  tubal  pregnancy,  603 
Hydrocele,  716 

radical  operation,  717 

tapping,  716 
Hypodermoclysis,  56 
Hysterectomy,  603 

Ice,  appendicitis,  493 
Ileus,  postoperative,  517 
Iliac  abscess,  356 
Ilio-inguinal  nerve  injury,  307 
Imperforate  anus,  584 
Incised  wounds,  70 

of  elbow,  90 

of  neck,  83 

of  wrist,  88 
Infected  wounds,  76 
Infections,  acute,  358 
Inferior  maxilla  fracture,  180 
Infiltration  of  urine,  633 
Ingrowing  toe-nail,  721 
Inguinal  hernia,  anatomy,  534 

radical  cure,  557 


r.l'l  \. 


7  1' 


Inguinal  hernia,    trangulated,  533 
Injuries,  abdi imen,  1 1 1 

joints,  25a 

nerves,  -"<m 

t  In  trax,  99 

hand,  96 
1 1:  t  rument  s,  emer 

cleansing,  5 

preparal  n  »n,  7 
[ntercostal  artery,  hemorrha] 
Internal  mammary  artery,  65 
Interrupted  suture 
Interstitial  hernia,  5 13 

tubal  pregnancy,  '>o^ 
I  ntestinal  anastomosis,  573 

obstructi*  m,  acute,  508 
gastric  lavage,  510 
(apart >t< >my,  5 1 2 

rectal  enema,  510 

symptoms,  509 

treatment,  510 
reseetii  >n,  57  1 
Intestines,  suture,  47; 
wounds.  473 

Intracapsular  fracture,  :ji 
Intracranial  hemorrhage,  444 
Intravenous  infusion,  hemorrhage, 

56 

shock,  52 

technic,  56 
Intussusception,  513 
Iodine,  sterilization  of  the  skin,  10 
Irrigator,  3 

Ischiotic  dislocation,  274 
Ischio-rectal  abscess,  337 

Jaw.  dislocation,  266 

fracture    180 
gunshot,  157 
Joints,  contusions,  281 

dislocations,  252 
compound,  278 

gunshot  wounds,  141,  163 

hemorrhage  into,  142,  [64 

injuries,  252 

incised  wounds,  282 

punctured  w.  mnds,  281 

sprains,  jNj 

stal>  wounds,  281 

suppurations,  376 

Keen.  Cesarean  section,  607 
Kelley,  t'  irsions,  589 
Kidney,  absces 

hemorrhage,  1.73 


Kidney,  injuii) 
rem<  >val 
rupture,  183 

wound 

Killian,  br< mch<  1  >■. ipy, 

fracl ure  1  ,  [88 

Km  >i  t .     ut  ure  1  if  liver,   171; 
Kollman,  filiform  guide,  624 

K(  timer,  Cesarean    ie<  1  i'  'ii.  6    7 

ECdnig,  preparation  of  the  skin,  10 
Knee,  amputatii »n,  695 

arthrotomy,  377 

bandage,  s? 

c<  mtusions,  281 

disl< icati< nis,  276 

gunshot  \\i mmls  1  (j,  163 

puncture,  382 

sprains,  282 

stab  wounds,  281 

wounds,  281 
Kiitner,  wounds  of  lung,  159 
Kyle,  foreign  body  in  nose,  392 

Labium,  abscess,    ;  \6 
Lacerated  wounds,  73 
Laceration  of  brain,  169 
Lachrymal  abscess,  319 
Lanphear,  Cesarean  section,  605 
Laparotomy  for  Cesarean  section 
604 

general  technic,  463 

gunshot  wounds,  civil,  159 
military,  145 

intestinal  obstruction,  510 

for  traumatism,  469 
Laplace,  peritonitis,  507 
Laryngotomy,  420 
Larynx,  foreign  bodies,  396 

wounds,  85 
Lateral  anastomosis,  intestine,  580 

sinus  thrombosis,  455 
Lavage,  gastric,  14,  510 
Leg,  amputations,  693 

bandage,  36 

fractures,  236 

osteomyelitis,  372 
Lejars,  appendicitis,  193 

reduction  of  shoulder.  253 
thumb,  269 

rupture  1  >f  the  lung,  103 

splint  for  leg,  239 

preparations  for  operation,  7 

Lembert  suture,   17(1 

Lichtenstern,  torsi, m,  595 


742 


INDEX. 


Ligation  en  masse,  60 
Ligations,  anterior  tibial,  646 

arterial,  638 

axillary,  643 

brachial,  643 

common  carotid,  640 

dorsalis  pedis,  647 

external  carotid,  641 

facial,  641 

femoral,  646 

lingual,  641 

occipital,  641 

posterior  tibial,  647 

radial,  644 

subclavian,  641 

superior  thyroid,  641 

ulnar,  645 
Lingual  artery,  ligation,  641 
Link,  tracheotomy,  419 
Lipomas,  removal,  726 
Lips,  wounds,  81 
Little  toe,  682 
Liver,  hemorrhage,  473 

injuries,  478 

suture,  479 
Local  anesthesia,  17 
Lower  extremity,  fractures,  223 
Lower  jaw,  dislocation,  266 
Lowery,  compound  fracture,  248 
Luckett,    Fourth-of-July    injuries, 

166 
Ludlow,  wounds,  diaphragm,  109 
Ludwig's  angina,  323 
Lung,  abscess,  436 

gunshot  wounds,  132 

hernia,  107 

rupture,  104 

stab  wounds,  105 

suture,  425 

Malar  bone  fracture,  180 
Malaleuca  sempervirens,  622 
Mammary  gland  abscess,  330 
Marsee,  fracture  of  fingers,  221 

injuries  to  hand,  96 

suture  of  tendons,  291 
Martin,  Cesarean  section,  606 
Mastoid  operation,  455 
Mastoiditis,  455 
Materials  for  sutures,  23 
Mayo,  umbilical  hernia,  554 
Mayor's  sling,  186 
Maxilla,  fractures,  180 
Meatus,  foreign  bodies,  389 


Median  nerve  exposure,  298 

injury,  297 
Meningeal  hemorrhage,  177 
Metacarpals,  fracture,  220 
Metal  splints,  46 
Mesentery,  hemorrhage,  472 

repair,  473 
McEwen,  strangulated  hernia,  545 
McFarland,  antitetanic  powder,  167 
McGrath,  appendicitis,  494 
Middle   meningeal   artery,  hemor- 
rhage, 177 
Miller,  pelvic  abscess,  351 
Miller,  kidney,  injury,  484 
Mitchell,  peritonitis,  506 
Morley,  bandage  for  head,  44 
Morris,  appendicitis,  489 
Morrison,  wounds  of  eye,  85 
Mosetig-Moorhof  bone  wax,  370 
Mothe,  dislocation  of  shoulder,  257 
Motor-oculi  nerve  injury,  297 
Mouth  burns,  409 
Moynihan,  intestinal  anastomosis, 

573 
purulent  peritonitis,  505 
Murphy  button,  579 

purulent  peritonitis,  505 
suture  of  arteries,  638 
olecranon,  218 
Musculo-cutaneous  nerve,  308 
Musculo-spiral  nerve  exposure,  302 
injury,  301 

Nares,  plugging,  66 

Nasal  bone,  fracture,  179    - 

septum  abscess,  318 
Nassau,  esophagotomy,  422 
Nausea,  anesthesia,  16 
Neck,  bandage,  42 

wounds,  83 

gunshot,  144,  157 
Neff ,  rupture  of  urethra,  608 
Nelaton's  line,  225 
Nephrectomy,  483 
Nerve,  compression,  295 

contusion,  295 

grafting,  296 

suturing,  294 

wounds,  295 
gunshot,  123 
Nerves,  individual,  296 

abducens,  297 

anterior  crural,  303 

auditory,  297 


[NDEX. 


743 


Nerves  circumflex,  302 
facial,  296 
fifth,  297 

genito  crural,  307 
llio-inguinal,  .,07 
laryngeal,  297 
median,  299 
motor-oculi,  297 
musculocutaneous,  308 
musculo  1  spiral,  301 

1 .1  it  nr.it.  >r,  306 
optic,  296 

peroneal,  308 
phrenic,  297 
pneumogastric,  297 
pi  ipliteal,  308 

radial,  301 

recurrent  laryngeal,  jijj 

sciatic,  307 

til>ial  anterior,  309 
]m  isterii  >r,  ,^0(j 

trifacial,  2qj 

ulnar,  299 
Noble,  Cesarean  section,  606 
Noetzel,  wounds  of  spleen,  4S2 
Nose,  foreign  bodies,  391 

hemorrhage,  65 

Obturator  artery  Ligation,  306 

dislocation,  276 

hernia,  strangulated,  554 

nerve,  306 
Occipital  artery  ligation,  641 
CEdema  of  the  glottis,  419 
1  E  it  I'hagotomy,  420 
CE  ophagus,  foreign  bodies,  392 

injuries,  83 
Ointment  of  Reclus,  408 
Olecranon,  fracture,  216 
Oliver,  strangulated  hernia,  545 

jaw  fracture,  181 
Omentum,  hemorrhage,  471 

resection,  568 

torsion,  596 
Open  wounds  of  thorax,  104 
Operative  wounds,  71 
Operation  in  private  houses,  6 
Opium,  appendicitis,  493 
Optic  nerve  injury,  296 
Os    calcis,   Pirogoff's  amputation, 

689 
Oschner,  appendicitis,   m( 

femoral  hernia,  569 

torsion,  592 


1 1  tei  »myeln  ii ,  acute,  369 

lemur,  37 1 

humerus,  .,7 1 

tibia,  37a 
( tvarian  cysts,  t<  »r  >ii  m  1 A  pedicle, 590 

•1  itecher,  linen,  1  \ 
Palmar  abscess,  33s 

arches,  63 

Panaris,  359 

Pancreas,  gunsh  »1  wounds,  135 

injuries,  481 
suture,    pi 

Paraphimosis,  710 

Paracentesis,  eardrum,    1.56 
pericardium,    1.33 

1  ileura,  438 
Parotid  gland  abscess,  320 

Patella,  dislocation,   277 

fracture,  231 

wiring,  2^ 
Peck,  wounds  ol   heart,  432 
Pedicles,  ligation,  590 
Pelvic  abscess,  348 
Pelvis,  fractures,  245 
Penis,  injuries,  118 
Perborate  of  soda,  epistaxis,  67 
Peri-anal  abscess,  340 
Pericardiotomy,  435 
Pericardium,  paracentesis,  433 

puncture,  433 

suture,  430 

wounds,  no 
Perineal  abscess,  341 

bruises,  635 

section,  636 
Peritonitis,  purulent,  506 

treatment,  507 

typhoid,  506 

septic,  506 
Peroneal  nerve,  308 
Pfaff,  appendicitis,  492 

tubal  pregnancy,  602 
Phalanges,  fractures,  220 
Pharynx,  foreign  bodies,  392 
Phimosis,  710 

Phlegmon,  362 

arm,  366 
fingers,  362 
f(  irearm,  365 
neck,  367 
perineum,  635 
tendon  sheaths,  362 
Phrenic  nerve,  297 


744 


INDEX. 


Picric  acid,  burns,  408 
Piles  operation,  704  ■ 
Pinna,  wounds,  80 
Pirogoff 's  amputation,  689 
Plantar  abscess,  337 
Plaster-of-Paris  bandages,  46 

preservation,  4 

splints,  47 

Bavarian,  48 
Pleura,  empyema,  439 

incision,  439 

puncture,  438 

wounds,  105 
Pneumogastric  nerve,  297 
Pneumothorax,  101 
Poisoned  wounds,  68 
Popliteal  abscess,  335 

artery  compression,  64 
Porter,  treatment  of  wounds,  75 
Posterior  nares,  plugging,  66 

tibial  artery,  647 
nerve,  309 
Post-operative  ileus,  517 
Potain's  aspirator,  438 
Pott's  fracture,  242 
Precordial  wounds,  no 
Pregnancy,  extra-uterine,  597 
Preparation,      emergency     opera- 
tions, 8 

hands,  9 

skin,  8 
Primary  hemorrhage,  54 
Probang,  foreign  bodies,  395 
Preperitoneal  hernia,  543 
Prostatic  abscess,  341 
Psoas  abscess,  355 
Pulse,  abdominal  injury,  113 

appendicitis,  490 

chloroform  anesthesia,  12 

ether  anesthesia,  14 
•   hemorrhage,  55 

shock,  50 
Puncture,  bladder,  628 

knee  joint,  382 

pericardium,  433 

pleura,  438 

scrotum,  716 
Punctured  wounds,  73 
Purulent  pleurisy,  436 

Quadriceps  extensor  tendon,  rup- 
ture, 285 
Quinsy,  325 
Quenu,  preparation  of  room,  8 


Radial  artery,  compression,  63 
ligation,  644 

synovial  sheath  drainage,  363 
Radius,  fractures,  210 

gunshot,  139 
Ranzi,  torsions,  590 
Reclus,  lacerated  wounds,  95 

ointment,  408 
Rectal  injections,  511 
Rectum,  abscess,  340 

dilatation,  703 

foreign  bodies,  399 

hemorrhoids,  704 

wounds,  121 
Recurrent  laryngeal  nerve,  297 
Reduction  "en  masse,"  532 

dislocations,  253 

fractures,  191 

hernia,  531 
Removal  of  small  tumors,  724 
Respiratory  paralysis,  14 
Responsibility   of   general    practi- 
tioner, 2 
Retention  of  urine,  619 
Retropharyngeal  abscess,  326. 
Reverdin,  skin  grafting,  727 
Ribs,  fracture,  183 

resection,  438 
Robinson,  shock,  53 
Romer,  fracture,  clavicle,  185 
Rongeur  forceps,  445 
Rossi,  fractures,  193 
Rosving,  appendicitis,  489 
Roux,  femoral  hernia,  572 
Royster,  fracture  of  humerus,  201 
Rubber  gloves,  9 
Rugine,  440 
Rupture,  tubal  pregnancy,  598 

urethra,  612 
Russ,  fracture  of  thumb,  223 

Saber  splint,  154 

Sacro-iliac  synchondrosis,  246 

Saline  solution  in  hemorrhage,  56 

sepsis,  505 
Sayres'  dressing,  185 
Scalds,  405 
Scalp,  abscesses,  316 

arteries,  63 

hematoma,  172 

wounds,  78 
Scapula  amputations,  679 

fracture,  243 
Schaute,  Cesarean  section,  607 


I\l>l  \. 


7  15 


Schell,  <  '<•  sarean  >e»  t ii m,  (>o(i 
Schleich's  formulae,  [9 
Sciatic  nerve  injury,  307 
Sclerotic  w< >und 

Sic  ip(  .1. iininc  narci  isis,  1  1 

Scr(  itum,  injuries,    1  iS 

Scudder,  fracture  1  if  leg,  239 
Sebaceous  cysts,  removal,  7-1 
Seec  mdary  hemorrhage,  5 1 
Semilunar    cartilages,  dislocation, 

Seminal  ducts  abscess,  3  |^ 
Senn,  first  aid  on  battlefield,   1  |8 

I'raet  ure  i  if  lemur,  :.•(■ 

hip-joint  amputal  i'  in,  699 
intussusception,  514 

Septic  arthritis,   <;<> 
Septum  nasi  abscess,  318 
Shaving  skin,  s 
Shell  wounds,  1  i'> 

She  >ek,  40 

diagnosis,  50 

treatment,  5  1 

Shoulder  amputation,  674 

arthrotomy,  385 

bandage,  42 

dislocations,  252 
fractures,  198 
Shrapnel!  wounds,  146 
Silk  sutures,  23 
Silkworm  sutures,  24 
Simons,  crushing  wounds,  94 
Skin  grafting,  727 

preparal  ii  in,  10 
Skull,  bullet  wounds,  127,  155 

fracture,  base,  C69 
compound,  173 
vault,  171 

trephining,  444 
Spence,  shoulder  amputation,  680 
Spermatic  cord,  ligation,  720 

torsion,  593 

vasectomy,  345 
Spica  f<  >r  breast .  1 1 

foot,  36 

gr<  'in,  38 

shoulder,  12 
Spinal  anesthesia,  20 

cord  injuries,  179 
Spine,  fractures,  1 78 

gunshot  wounds,  130,  [57 

wounds,   1  1  7 
Spleen,  hem<  irrhage,  |J8] 

injuries,   (Si 


,  rem<  >va 

ruptun 

\> irsii >n,  595 
Splenectomy,  . 
Splint,  Bavarian,  18 

I  lupuytren'i  , 

fir   t   aid,    1  S  1 

I  [odgen's,  1  1 1 
Splint  },    1  ^ 

I  >utch  cane,  45 

metal,    \(< 

plaster  1  if  Pari  1,  [6 

silicate  I  if  1"  itash,    l  , 
w<  Milieu,  45 
wire  gauze,    [6 

Sprains,  283 

St .  Andrew's  cri  iSS,  40 
Stab  wounds,  72 

abdomen,   1  1  5 

heart,    1.25 

knee,    28l 

thigh,  88 

thorax,  104 
Sterilization,  dressing,  7 

hands,  9 

instruments,  8 

skin,  10 
Stimson,  pain  in  fracture,  190 
Stomach,  hemorrhage,  135 

hernia,  545 

suture,  478 

wounds,  478 
Stewart,  suture  of  heart,  431 
Stovaine,  spinal  anesthesia,  20 
Strangulated  hernia,  528 

complications,  541 

diagnosis,  529 

femoral,  533 

inguinal,  533 

obturator,  554 

1  iperation,  533 

taxis,  530 

umbilical,  549 
Stricture  of  urethra,  619 
Stump  bandage,  15 
Subclavian  artery,  compression,  63 

ligation,  641 
Subclavicular  dislocation,  256 
Subcutaneous  wounds,  69 
Subcuticular  suture,  28 
Subglenoid  dislocation,   2(>2 
Submammary  abscess. 
Submaxillary  abscess. 


746 


INDEX. 


Subphrenic  abscess,  351 
Subpubic  dislocation,  275 
Subspinous  dislocation,  265 
Suicide,  attempts,  155 
Superior  maxilla  fracture,  180 

thyroid  artery  ligation,  641 
Suprapubic  cystotomy,  617 

puncture,  628 
Surgical  dressings,  32 
Suture  of  arteries,  638 

bladder,  486 

heart,  430 

intestine,  475 

liver,  479 

lung,  425 

nerves,  294 

pancreas,  481 

tendons,  289 

ureter,  486 

wounds,  23 
Sutures,  catgut,  24 

continuous,  24 

horsehair,  23 

interrupted,  25 

Lembert,  476 

linen,  24 

methods  and  materials,  23 

quilted,  24 

sero-serous,  476 

silk,  23 

silkworm-gut,  24 

subcuticular,  28 
Syme's  amputation,  687 
Syncope,  55 
Synovial  sheath  suppurations,  361 

cysts,  726 

Tampon     for     intercostal    hemor- 
rhage, 65 
Tapping,  hydrocele,  716 
Tarso-metatarsah  amputation,  683 
Tarsus,  dislocations,  277 

fracture,  250 
Taxis,  indications,  530 

technic  femoral  hernia,  533 
inguinal  hernia,  531 
umbilical,  533 
Taylor,  empyema,  436 

fracture  of  humerus,  202 
Temporal  artery  compression,  63 
Temporo-maxillary   joint   disloca- 
tion, 266 
Tendon,  dislocations,  284 
divided,  288 


Tendon,  rupture,  284 

suture,  289 

wounds,  284 
Testis,  removal,  718 

suture,  119 

wounds,  119 
Tetanus,  bolo  wounds,  147 

Fourth-of-July  injuries,  166 

prophylaxis,  166 

punctured  wounds,  73 
Thiersch,  skin  grafting,  728 
Thigha,  mputations,  697 
Thoracotomy,  indications,  423 

technic,  423 
Thorax,  injuries,  99 
Throat,  cut,  83 
Thrombosis,  lateral  sinus,  455 
Thumb,  amputations,  661 

bandage,  41 

dislocations,  268 

fracture,  223 
Tibia,  fractures,  236 

osteomyelitis,  372 

trephining,  373 
Tibial  arteries,  ligation,  646 

compression,  64 
Tillaux's  dressing,  228 
Toe-nail,  ingrowing,  721 
Toes,  amputation,  680 
Tongue,  abscess,  325 

suture,  82 

wounds,  82 
Tongue-traction,  asphyxia,  15 
Tonsil,  abscess,  325 
Torsion,  arteries,  59 

diagnosis,  589 

omentum,  596 

pedicle  ovarian  cysts,  589 
spleen,  595 

spermatic  cord,  593 

uterus,  591 
Townsend,  catheterization,  622 
Trachea,  foreign  bodies,  396 

gunshot  wounds,  144 

incised  wounds,  85 
Tracheotomy,  after-treatment,  418 

foreign  bodies,  417 

indications,  413 

operations,  413 

tubes,  413 
Travers,  suture  of  the  heart,  431 
Trephining,  femur,  374 

fracture  of  skull,  444 

humerus,  374 


[NDEX. 


717 


Trephining,  tibia,  .^7-: 
Trephine,  I  )■  iycn,   1  \8 

Gait,  us 
IV.    es,  strangulated  hernia,  538 
Trunk  injuries,  >)<> 
Tubal  pregnancy,  diagnosis,  598 

operal  i<  in,  599 

rupture,  597 
rubercular  abscess,  ,;  1 5 
Tumors,  superficial,  72  1 
Turpentine  burns,  408 
Tunica  vaginalis,  resection,  717 
Tuttle,  imperforate  anus,  588 
Tvpli'  'id  perfi  >rati<  in,  507 

(Tina,  fraci  ures,  210 
LMnar  artery,  ligatii m,  <<  [$ 

nerve  exposure,  299 
injury,  299 

synovial  sheath,  363 
Umbilical      hernia,     strangulated, 

549 
radical  cure,  550 
Ureter,  repair,  487 

wounds,  4S7 
lira,  anatomy,  610 
catheterization,  620 
contusions,  611 
foreign  bodies,  402 
rupture  bulbous  portion,  612 
diagnosis,  608 
membranous  portion,  618 
pendulous  portion,  618 
symptoms,  609 
treatment,  612 
Jrethral  forceps,  402 
Urethrotomy,  612 
Hrgent  craniectomy,  444 

thoracotomy,  423 
Jrinary  abscess,  633 
Jrine,  extravasation,  633 

retention,  619 
Jterus,  torsions,  591 

Van     der     Walker,    emergency 
surgery,  6 

ifegina,  abscess,  346 
injuries,  118 

Vagus  nerve,  297 

Van  Hook's  anastomosis,  4N7 

Valentine,  emergency  catheteriza- 
tion, 622 

Vasectomy,  3  \^ 

Vaughn,  wounds  of  heart,    11  _• 


Vault  ' >!  skull  fraci ure,  1 7 1 

compound,  17s 
Veins  <»f  Liver,  ligal \> in,  1 7 •  ^ 
Velpeau1    bandage,  [84 
Vem 'us  hem' irrhage,  ^  1 
Vincenl ,  t  rephining,  1.5a 
Vim  l  ierg,  t  ubal  pregnancy,  s<;s 
Vertel  irae,  fra<  1  ures,  1 78 
V i  ■  era,  abd< iminal,  rupture,  1  \ ; 
Volvulus,  510 
Von     Bergman,  gunshol    wounds, 

1 27 
Vulvar  abscess,  3  \.6 
Vulvo-vaginal  abscess,  346 

injuries,    1  c8 
Waite.  shock,  49 

Walker,  fractures  of  femur,  227 
Warbasse,  treatment   of   fracture, 

192 
Wathen,  wounds  of  liver,  47c) 
Westmoreland,  tracheotomy,    117 
Whitman,  fracture  of  femur,  227 
Wick  drains,  30 
Wire  gauze  splints,  46 
Wiring  fractured  fingers,  222 

olecranon,  216 

patella,  233 
Wooden  splints,  45 
Wounds,  abdomen,  114 

aseptic,  70 

base  of  thorax,  108 

bend  of  elbow,  90 

bladder,  485 

blank  cartridge,  166 

bolo,  146 

chest,  104 

cleansing,  75 

contused,  69 

definitions,  68 

diaphragm,  no 

drainage,  89 

dressings,  75 

elbow,  90 

eye,  85 

eyelids,  82 

extremities,  87 

face,  81 

femoral  artery,  88 

fingers,  95 

general  principles,  68 

gunshi  it,  civil,  1 55 
military,   u: 

hand,  <)(> 


748 


INDEX. 


Wounds,  head,  78 
heart,  no 
hemorrhage,  70 
incised,  70 
infected,  76 
intestine,  475 
kidney,  483 
lacerated,  73 
larynx,  85 
lips,  81 
liver,  478 
lung,  105 
neck,  83 
operative,  71 
pancreas,  481 
penis,  118 
pericardium,  no 
pinna,  80 
pleura,  105 
precordial,  no 
punctured,  73 
rectum,  121 
scalp,  78 
scrotum,  118 
shell,  146 

special  regions,  78 
spine,  117 


Wounds,  spleen,  481 

stab,  72 

stomach,  478 

subcutaneous,  69 

suture,  24 

symptoms,  69 

testicle,  119 

thigh,  88 

thorax,  99 

trachea,  85 

treatment,  70 

tongue,  82 

toy  pistols,  166 

ureter,  487 

vagina,  118 

vulva,  118 

wrist,  88 
Wrist,  arthrotomy,  384 

dislocation,  280 

fractures,  219 

wounds,  88 

X-ray,  foreign  bodies,  394 
fractures,  191 

Zone  of  anesthesia,  18 


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